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Oxygen Saturation Nomogram in Newborns Screenedfor Critical Congenital Heart Disease

WHATS KNOWN ON THIS SUBJECT: Universal oxygen saturationscreening by pulse oximetry is now recommended for early

detection of critical congenital heart disease. The distribution of

saturations in asymptomatic newborns in a large population has

not been described.

WHAT THIS STUDY ADDS: Our study is the largest to date to

establish simultaneous pre- and postductal oxygen saturation

nomograms in asymptomatic newborns at 24 hours after birth.

The mean postductal saturation is higher than preductal during

this time.

abstractOBJECTIVE: To establish simultaneous pre- and postductal oxygen

saturation nomograms in asymptomatic newborns when screening

for critical congenital heart disease (CCHD) at 24 hours after birth.

METHODS:Asymptomatic term and late preterm newborns admitted to

the newborn nursery were screened with simultaneous pre- and post-

ductal oxygen saturation measurements at 24 hours after birth. The

screening program was implemented in a stepwise fashion in 3

different afliated institutions. Data were collected prospectively from

July 2009 to March 2012 in all 3 centers.

RESULTS:We screened 13 714 healthy newborns at a median age of 25

hours. The mean preductal saturation was 98.29% (95% condence

interval [CI]: 98.2798.31), median 98%, and mean postductal satura-

tion was 98.57% (95% CI: 98.5598.60), median 99%. The mean differ-

ence between the pre- and postductal saturation was 20.29% (95%

CI: 20.31 to 20.27) with P, .00005. Its clinical relevance to CCHD

screening remains to be determined. The postductal saturation was

equal to preductal saturation in 38% and greater than preductal

saturation in 40% of the screens.

CONCLUSIONS:We have established simultaneous pre- and postductaloxygen saturation nomograms at 24 hours after birth based on

.13 000 asymptomatic newborns. Such nomograms are important to

optimize screening thresholds and methodology for detecting CCHD.

Pediatrics 2013;131:e1803e1810

AUTHORS:Priya Jegatheesan, MD,

a

Dongli Song, MD, PhD,

a

Cathy Angell, MD,a,b Kamakshi Devarajan, MD,c and Balaji

Govindaswami, MBBS, MPHa

aDepartment of Pediatrics-Neonatology, Santa Clara Valley

Medical Center, San Jose, California; bDepartment of Pediatrics-

Neonatology, OConnor Hospital, San Jose, California; andcDepartment of Pediatrics-Neonatology, St. Francis Medical

Center, Lynwood, California

KEY WORDS

critical congenital heart disease, universal screening, pulse

oximetry screening, oxygen saturation screening, oxygen

saturation nomogram, pre- and postductal saturations,

asymptomatic newborns

ABBREVIATIONS

CCHDcritical congenital heart disease

CIcondence interval

Dr Jegatheesan designed the study, designed the data collection

instruments, supervised data collection, performed the data

analysis, drafted the initial article, revised and approved the

nal article as submitted; Dr Song designed the study, reviewed

the analysis, critically reviewed the article, and approved the

nal article as submitted; Drs Angell and Devarajan coordinated

and supervised data collection at 1 of the 3 sites, critically

reviewed the article, and approved the nal article as

submitted; and Dr Govindaswami conceptualized and designed

the study, critically reviewed the article, and approved the nal

article as submitted.

www.pediatrics.org/cgi/doi/10.1542/peds.2012-3320

doi:10.1542/peds.2012-3320

Accepted for publication Feb 8, 2013

Address correspondence to Priya Jegatheesan, MD, Division of

Neonatology, Department of Pediatrics, Santa Clara Valley

Medical Center, 751 South Bascom Ave, San Jose, CA 95128.

E-mail: [email protected]

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).

Copyright 2013 by the American Academy of Pediatrics

FINANCIAL DISCLOSURE: The authors have indicated they have

nonancial relationships relevant to this article to disclose.

FUNDING: Supported by Santa Clara County First Five Program.

PEDIATRICS Volume 131, Number 6, June 2013 e1803

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Critical congenital heart disease (CCHD)

is dened as congenital heart disease

that requires surgical intervention

during infancy for survival. This occurs

in 1 to 2/1000 live births, and fewer than

50% of these conditions1 are diagnosed

prenatally. Some newborns with CCHDremain asymptomatic in the rst few

days after birth. Physical examination

fails to identify 30% to 50% of CCHD

before discharge.2 Delay in identica-

tion of CCHD leads to severe morbidity

or mortality as many of these un-

diagnosed newborns become critically

ill with cardiovascular collapse. Pulse

oximetry screening can be used to

identify CCHD in asymptomatic new-

borns to lessen the burden of un-diagnosed CCHD.35 Multiple studies

have evaluated different screening

methodologies including postductal ox-

ygen saturation measurements alone,69

or both pre- and postductal4,10 satu-

rations. There are also considerable

differences in both the timing of

screening (from 4 to 2472 hours after

birth)610 and the threshold values

(from #92% to #96%). This has led to

widely varying sensitivity from 50% to100% and false-positives from 0.01%

to 5.6%. Increasing the sensitivity and

reducing the false-positive rate requires

optimizing the screening methodology.

Accuracy and efcacyof CCHD screening

programs depend on understanding

oxygen saturation distribution in new-

borns in the rst few days after birth.

Oxygen saturation in newborns in the

rst week after birth was described in

an early physiology study11 whereinblood gas oxygen saturation was mea-

sured by cooximetry. Subsequent

studies have used noninvasive pulse

oximetry to measure oxygen saturation.

Our current knowledge of oxygen satu-

ration in newborns comes from studies

done immediately after birth1216 and in

the rst 24 hours after birth.12,1720

Some studies have assessed oxygen

saturation from single sites alone and

others from both pre- and postductal

sites. The pre- and postductal satu-

rations were obtained by sequential

measurements15,18,19 in some studies

and by simultaneous measurements in

others.12,16 Rosvik et al20 described

postductal saturation in the rst 6

hours in .6800 newborns screened

for CCHD, but there has been no similar

study using both pre- and postductal

oxygen saturation.

We implemented a pulse oximetry

screening program in our institution in

August 2009, following the de-Wahl

Granelli method, which included pre-

and postductal saturation screening10

and the Koppel method of screening

after 24 hours.6 In addition, we mea-

sured pre- and postductal saturations

simultaneously instead of consecu-

tively. Evaluating pre- and postductal

oxygen saturation in large numbers of

asymptomatic newborns is essential in

dening threshold values for CCHD

screening. The objective of this study

was to describe the distribution of si-

multaneous pre- and postductal oxygen

saturation in asymptomatic newborns

who undergo screening for CCHD at

24 hours after birth.

METHODS

Program Sites

We implemented the pulse oximetry

screening program in a stepwise

manner in 3 institutions. A pilot pro-

gram was implemented in August 2009

at our primary site, center 1 (Santa

Clara Valley Medical Center, San Jose,CA, a public hospital with 5000 de-

liveries annually with a regional level 3

NICU). We subsequently expanded to

universal screening in January 2010.

Universal screening was implemented

in July 2011 at center 2 (OConnor

Hospital, San Jose, CA, a nonprot

hospital with 4000 deliveries annu-

ally with a community level 3 NICU), andin January 2012 at center 3 (St. Francis

Medical Center, Lynwood, CA, a non-

prot hospital with 6000 deliveries

annually with a community level 3

NICU). All 3 centers are at sea level

(,100 ft elevation).

Subjects

Asymptomatic newborns born at $34

weeksgestation admitted to the new-

born nursery were screened utilizingpulse oximetry for CCHD at 24 hours

after birth.

Screening Method

Simultaneous pre- and postductal oxy-

gen saturations of all asymptomatic

newborns were recorded by nursing

staff at 24 hours after birth. We used

reusable probes with disposable wrap

($1.4$1.9/disposable wrap; Masimo

Corporation, Irvine, CA). The probeswere placed on the right palm or wrist

for preductal and on either foot for

postductal saturation. The oxygen sat-

uration values were recorded when

both pre- and postductal pulse oxime-

try had stable waveforms and their

heart rates were correlating. The

equipment and pulse oximetry tech-

nology used in all 3 institutions were

newer-generation, motion-tolerant devi-

ces (Table 1) with 8 to 10 seconds aver-aging time. The pulse oximetry screen

was considered pass if either the

TABLE 1 Pulse Oximetry Screening Equipment

Pulse Oximetry Equipment/Technology Probes

Center 1 a

Masimo Rad-87/SET Reusable

Center 2 Masimo Rad-5/SET andb

Philips/FAST Reusable

Center 3 Masimo Rad-87/SET Reusable

FAST, Fourier artifact suppression technology; SET, signal extraction technology.a Masimo (Masimo Corporation, Irvine, CA).b Philips (Philips Healthcare, Andover, MA).

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pre- or postductal saturation was

$95% and the difference between the

2 was #3%. The screen was consid-

ered a fail if either the pre- or post-

ductal saturation was ,90%. A fail

triggered a prompt clinical evaluation

by a pediatric provider and transfer tothe NICU if indicated. The screen was

repeated if either the pre- and post-

ductal saturations were 90% to 94%, or

there was a .3% difference. If the re-

peat screen within 4 hours remained

the same, then it was considered a fail.

Failed screens were followed with an

echocardiogram before discharge.

Data Collection

The oxygen saturation values of allscreens from August 2009 to March

2012 were documented by nursing staff

and entered into study data set by

a research assistant. The number of

repeat screens was also collected.

Those screens that had either pre- or

postductal values missing were re-

moved from the data set. Additional

variables collected in a subset of

newborns included the following: ges-

tational age, birth weight, gender, anddelivery type.

Data Analysis

The distribution of simultaneous pre-

and postductal oxygen saturations and

their differences is presented in a box

plot and summarized as means with

95% condence intervals (CIs) and

medians with percentiles. The mean,

median, and percentile values for the

subgroups based on center, gender,gestational age (preterm versus term),

and age of screening (,20 hours, 21

28 hours, 2936 hours, 3748 hours,

and .48 hours) were calculated. As

the oxygen saturations were not nor-

mally distributed but were skewed to

the left, nonparametric tests were used

for comparisons. Pre- and postductal

saturations and their differences were

compared between groups by using

the Wilcoxon Mann-Whitney rank sum

test and the Kruskal-Wallis test (for

multiple groups). The paired pre- and

postductal oxygen saturation differ-

ences were compared by using the

Wilcoxon signed rank test. Statistical

data analysis software Stata 10.0(Stata Corp, College Station, TX) was

used for the analysis.

The number of screens that needed to

be repeated per protocol, number of

fails per protocol, and the number of

protocol violations per center were

collected and summarized. Protocol

violations were dened as failure to

repeat a screen in newborns who met

criteria for rescreening and failure to

perform an echocardiogram in thosewho failed the screen.

RESULTS

Oxygen Saturation Nomograms

A total of 13 714 newborns were

screened. The mean preductal satura-

tion was 98.29% (95% CI: 98.2798.31),

and the median was 98%. The meanpostductal saturation was 98.57% (95%

CI: 98.5598.60), and the median was

99% (Fig 1A). Of screened asymptomatic

newborns, 99.5% had pre- or postductal

saturations $95%. Figure 1B reveals

the percentile distribution of the pre

and postductal oxygen saturations.

Pre- and Postductal Saturation

Difference

In our study, 99.5% of asymptomaticnewborns had a pre- and postductal

FIGURE 1A, Simultaneous pre- and postductal oxygen saturation nomogram in asymptomatic newborns. Si-

multaneous pre- and postductal oxygen saturation distribution in 13 714 asymptomatic newborns. The

boxes represent the interquartile range from 25th to 75th percentile. The marker within the box is the

median and the whiskersreach 1.5 times interquartile range. B, Percentile distribution of pre- and

postductal oxygen saturations.

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saturation difference of#3% (Fig 2).

Pre- and postductal saturations were

the same in 38%; preductal was

greater in 22%, and postductal was

greater in 40% of the screens. The

mean difference between pre- and

postductal saturation was 20.29%(95% CI: 20.31 to 20.27), which was

statistically signicant (P , .00005),

and the median was 0.

Subgroups

The mean, median, and the percentile

valuesof thepre-and postductal oxygen

saturation in the different subgroups is

shown inTable 2. There was no differ-

ence between the pre- and postductal

saturation in boys versus girls. Pre-ductal values in the cesarean delivery

group were higher than those de-

livered vaginally, but their postductal

saturations were not different. Post-

ductal saturation in preterm newborns

was lower than term newborns, but

their preductal saturations were not

different. Center 2 had a higher pre-

ductal saturation compared with the

others but not the postductal.

The mean difference between the pre-and postductal saturation ranged from

20.12 to20.33, which was statistically

signicant in all subgroups. There was

no signicant difference between boys

and girls, term versus preterms, or

cesarean delivery versus vaginal de-

livery. However, center 2 had a lower

difference of20.13 compared with 2

0.3 in the other 2 centers.

Age of ScreeningThe age of screening data were avail-

able in 13 287 newborns. The median

age of screening was 25 hours. Ninety-

seven percent of screening was done

between 21 and 36 hours. There was no

signicant difference in preductal or

between pre- and postductal satu-

rations between the age categories

(Table 3). Although postductal satura-

tion between the groups was statistically

different, it did not remain signicant

when individual groups were com-pared. The pre- and postductal oxygen

saturation differences ranged from20.21

to20.49 for all ages and are statistically

signicant.

Screening Program

In our study, on the rst screening, 13

615 (99.3%) passed, 8 failed, and 91

(0.66%) required a repeat (Fig 3). Of the

91, only 55 screens were repeated; 5

failed the repeat screen. There werea total of 42 (0.3%) protocol violations;

35 due to failure to repeat a screen, 1

due to obtaining an echo before repeat,

and 6 due to failure to obtain an echo

for oxygen saturation ,90%. The

number of repeats, protocol violations,

and failed screens by center is

shown in Table 4. In total, 8 echo-

cardiograms were done as a result of

the CCHD screen, and 2 of those

FIGURE 2Difference between pre- and postductal oxygen saturation in asymptomatic newborns. The difference

between simultaneous pre- and postductal oxygen saturation distribution in 13 714 asymptomatic

newborns. The box represents the interquartile range from 25th to 75th percentile. The marker within

the box is the median and the whiskersreach the 1.5 times interquartile range.

TABLE 2 Pre- and Postductal Oxygen Saturation Distribution in Subgroups

N Pre Post Difference Within group

Mean (Median,

1st99th Percentile)

Mean (Median,

1st99th Percentile)

Mean Pa

All 13 714 98.29 (98, 95100) 98.57 (99, 95100) 20.29 ,.00005

Boy 5689 98.25 (98, 95100) 98.58 (99, 95100) 20.33 ,.0001

Girl 5562 98.26 (98, 95100) 98.56 (99, 95100) 20.3 ,.0001

Between groupsPb

.8 .5 .4

Vagi nal delivery 654 98.45 (98, 95100) 98.78 (99, 96100) 20.33 ,.0001

Cesarean delivery 247 98.73 (99, 96100) 98.91 (99, 96100) 20.18 .024

Between groupsPb

.002 .1 .06

Term 2869 98.49 (99, 95

100) 98.67 (99, 96

100) 2

0.18 ,

.0001Preterm 122 98.25 (98, 94100) 98.38 (98, 94100) 20.12 .045

Between groupsPb

.1 .03 .96

Center 1 10 290 98.26 (98, 95100) 98.58 (99, 95100) 20.32 ,.0001

Center 2 2081 98.46 (98, 95100) 98.59 (99, 95100) 20.13 ,.0001

Center 3 1343 98.24 (98, 94100) 98.50 (99, 94100) 20.27 ,.0001

Between groupsPc

.0001 .5 ,.0001

, Data not applicable.a Pis from Wilcoxon signed rank test.b Pis from Mann-Whitney rank sum test.c Pis from Kruskal-Wallis multiple group comparisons.

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newborns had CCHD (Tetralogy of Fallot

and Ebstein anomaly).

DISCUSSION

Our study is the rst to establish si-

multaneous pre- and postductal oxygensaturation nomograms, at sea level, at

24 hours after birth, using a large

sample of .13 000 asymptomatic

newborns. We show that 99% of the

newborns have both pre- and post-

ductal saturations $95% and that the

preductal oxygen saturation is often

less than postductal at the time of

screening. This nding has not been

previously reported.

Weshow thatthemean (6 SD) pre- and

postductal oxygen saturations are

98.3 6 1.4 and 98.6 6 1.3, respectively.These values appear to be slightly

higher than those described in earlier

studies.11,12,18,21 In 1968, Koch et al11

used cooximetry from umbilical artery

blood gases in 17 newborns and

reported a mean (6 SD) postductal

oxygen saturation of 96.8 61.7 at 24

hours after birth. Dimich et al12

reported mean (6 SD) pre- and post-

ductal saturations of 95.7 6 2.2 and

95.26 2.3 at 24 hours in 100 newborns

by using Ohmeda pulse oximetry.

Fractional oxygen saturation measuredthis way may be up to 2% lower than

the pulse oximeters used in our study,

as it approximates the average car-

boxyhemoglobin and methemoglobin

levels present in healthy nonsmoking

adults.22 A recent study with newer

generation pulse oximetry describes

the mean pre- and postductal satura-

tion at 24 hours as 97.26 1.6.18 Despite

these discrepancies, all these studies

are consistent in revealing that a ma-jority of newborns have oxygen satu-

ration $95% at 24 hours after birth.

The difference between pre- and post-

ductal saturation has been described in

the rst few days after birth. Studies

done immediately after birth12,16 and

within 4 hours after birth15,18 have

revealed that the preductal is greater

than the postductal saturation. Lev-

esque et al18 described pre- and

postductal saturations measured con-secutively by using Novametrix pulse

oximetry on admission to the nursery,

at 24 hours and at discharge in

718 normal newborns. They reported

that there was a tendency for the pre-

ductal to be higher by 0.3% than post-

ductal at 2.7 hours after birth, but this

difference was not observed at 24

hours. Dimich et al12 measured pre- and

postductal saturations simultaneously

at 24 hours in 100 newborns with a dif-ferent pulse oximetry device (Ohmeda

Biox 3700) and showed that the mean

preductal saturation was higher than

postductal saturation (although it did

not attain statistical signicance). Our

observation that the mean preductal is

lower than the postductal saturation

has not been described previously. This

difference is very small (20.29%) and

within the inherent margin of error

TABLE 3 Pre and Postductal Oxygen Saturation Based on Age of Screening

Age of Screening, h n Preductal Postductal Difference Pa

Mean (Median,

1st99th Percentile)

Mean (Median,

1st99th Percentile)

Mean

#20 71 98.4 (99, 94100) 98.9 (99, 96100) 20.49 .001

2128 h 10 840 98.3 (98, 95100) 98.6 (99, 95100) 20.3 ,.0001

2936 h 1983 98.3 (98, 95100) 98.5 (99, 95100) 20.21 ,.0001

3748 h 234 98.2 (98, 95100) 98.5 (99, 96100) 20.23 .0039

.48 h 159 98.4 (99, 94100) 98.8 (99, 96100) 20.4 .0001

Between groupsPb

.6 .0015 .06

, Data not applicable.a Pis from Wilcoxon signed rank test.b Pis from Kruskal-Wallis multiple group comparisons.

FIGURE 3Screening program ow diagram.

TABLE 4 Screening Program

Total Screened Repeat Screens Protocol Violat ions Failed Screens

Center 1 10 290 62 29 4

Center 2 2081 11 8 3

Center 3 1343 18 5 6

Total 13 714 91 (0.7%) 42 (0.3%) 13 (0.1%)

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associated with pulse oximetry devices.23

Our study had a large sample size and

hence could detect very small differ-

ences. It is also possible that such

small differences can only be noted by

simultaneous measurements. It is un-

clear whether this observation isphysiologic or due to methodological

or technological bias. All 3 centers in

our study revealed that the preductal

saturation was lower than or equal

to the postductal saturation in most

cases. This observation is unlikely to be

due to random chance because the

same discrepancy was observed in all

3 centers despite the use of different

devices. Although this nding is of un-

clear clinical signi

cance, it may berelevant to the discussion of the opti-

mal screening methodology to detect

CCHD and requires further validation.

Deliveryroom studieshave revealed that

infants born via cesarean delivery have

lower oxygen saturation immediately

after birth and that it increases within

few minutes after birth.13,16,24,25 In-

terestingly, we found that both pre- and

postductal saturations 24 hours after

birth were slightly higher in those bornvia cesarean delivery compared with

those delivered vaginally, although only

the preductal saturation was statisti-

cally signicant. Another recent large

study also revealed higher postductal

saturation between 2 and 24 hours in

infants born by cesarean delivery.20

Again, the reason for this observation is

unclear. Multiple studies have revealed

that preterm newborns have lower

saturations at 5 minutes after birth.14,25

We found that this persists even at 24

hours. Even though these differences in

cesarean delivery versus vaginal de-

liveries and term versus preterm new-

borns are statistically signicant, they

are too small to indicate a different

threshold for CCHD screening.

Pulse oximetry hasbeen usedin multiple

CCHD screening studies since the early

2000s with different methods. The

variability of published false-positive

rates is most related to age at screen-

ing. Mahle et al26 summarized that the

false-positive rate was 0.035% when the

screening was done after 24 hours

compared with 0.9% for all studies in-

cluding early screening at 4 to 6 hours.Our experience reveals that very few

newborns (0.09%) fail the screen when

done at 24 hours. There is still con-

troversy regarding whether to do both

pre- and postductal screens or only

postductal for CCHD screening. There

were 2 cases in the 39 821 screened by

de Wahl Granelli et al,19 that were

detected only by the difference between

pre- and postductal difference. In our

experience, the nursing time for thetotal screen was,5 minutes, which led

to minimal increase in cost. We used the

reusable probe to do our screening that

led to an added cost of ,$1.5 per

screen. We followed the de-Wahl Granelli

method of screening both pre- and

postductal saturations to increase the

detection of CCHD cases and justied

the minimal added cost.4,19 In our study,

91 newborns required a repeat screen,

75% of which were triggered by a .3%difference; 90% passed the repeat

screen. The number of CCHD cases in

our study is too small to make any ar-

gument regarding single postductal

versus pre- and postductal screens. In

fact, the cumulative published satura-

tion experience to date may still be in-

sufcient to makeconclusions about the

optimal methodology for CCHD screen-

ing. Regardless of what methodology is

used, ongoing oxygen saturation datacollection in large numbers is essential

to better rene the thresholds for CCHD

screening in the future. Furthermore,

cost effectiveness analysis need to be

performed to address whether the

added cost of both pre and postductal

screening justify the benet of increase

in sensitivity to detect CCHD.

Our study protocol is identical to the

recent national recommendation put

out by the work group for the Secre-

tarys Advisory Committee on Heritable

Disorders in Newborns and Children,

which strategized implementation of

screening for CCHD27; therefore, it is

important to evaluate our protocol

adherence. We had successful protocoladherence in 99.7% of the newborns

from all 3 centers, demonstrating the

feasibility of this protocol. There were

42 (0.3%) protocol violations in our

study: 35 due to failure to repeat

a screen, 1 due to obtaining an echo

before repeat screening, and 6 due to

failure to obtain an echocardiogram

for oxygen saturation ,90%. Eight

newborns who failed the rst screen

with saturation ,90% should haveundergone an echocardiogram per

protocol, but 6 out of the 8 had a repeat

screen and passed. This suggests

a role for repeating the screen even

when 1 saturation is ,90% in asymp-

tomatic newborns. This would further

decrease the number of unnecessary

echocardiograms done due to failed

screens. As universal screening be-

comes more widespread, it is critical

that protocol adherence be monitoredcarefully.

One of the important limitations of our

study is that we do not have the out-

comes of all screened newborns, espe-

cially those with protocol violations who

did not get a repeat screen. We did have

follow-up data from readmissions with

CCHD, outpatient echocardiograms in

the rst year, and deaths due to CCHD in

the birthing county to identify missed

cases. However, linkage of the birthhospital data to the Society of Thoracic

Surgeons national database (STS) and

interventional cardiology, Improving

Pediatric And Adult Congenital Treat-

ment (IMPACT) data sets and deaths due

to undiagnosed CCHD is unavailable for

accurate identication of all missed

CCHD cases.28,29 We used only 2 types of

pulse oximetry devices in our study in

all 3 centers. The nding that mean

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postductal saturation is higher than

preductal saturation should be vali-

dated in other study settings with

other devices and technology. The

saturation data were recorded man-

ually by the nurses who performed

the screen, leaving room for humanerror during transcription, and sys-

tematic bias of picking the highest

number with an intention to pass. A

more accurate method would be to

download the pulse oximetry data

electronically.

CONCLUSIONS

Pre- and postductal oxygen saturation

nomograms from large numbers are

essential to further rene methodology

forCCHDscreening.Henceongoingdata

collection and review of newborn pop-

ulations screened for CCHD is essential.

Linkage of the birth hospital data to

cardiothoracic surgery data sets such

as STS and IMPACTand to vital statistics

are essential to accurately identify all

CCHD cases missed by screening.

ACKNOWLEDGMENTS

We thank the postpartum unit nurses

and nursing and physician leaders at

allsiteswhoplayedamajorroleinimple-

menting the screening program. We

thankBen KieandPoojaRathi(summer

students),Malchelnil Cormier, and RobinWufor theirhelpwithdatacollection. We

also thank Neil Finer, MD, Anne de-Wahl

Granelli, PhD, and Scott Grosse, PhD, for

their guidance, and Jacqueline Anne

Noonan, MD, for her comments early

in our screening program.

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DOI: 10.1542/peds.2012-3320; originally published online May 20, 2013;2013;131;e1803Pediatrics

GovindaswamiPriya Jegatheesan, Dongli Song, Cathy Angell, Kamakshi Devarajan and Balaji

Heart DiseaseOxygen Saturation Nomogram in Newborns Screened for Critical Congenital

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DOI: 10.1542/peds.2012-3320; originally published online May 20, 2013;2013;131;e1803PediatricsGovindaswami

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Heart DiseaseOxygen Saturation Nomogram in Newborns Screened for Critical Congenital

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