Screening with Pulse Oximetry for Early Detection

of Neonatal Hypoxemia
Augusto Sola, MD,*‡ Sergio G. Golombek, MD, MPH, FAAP†‡
*Department of Epidemiology and Community Health, School of Health Sciences and Practice, New York Medical College, Valhalla, NY;
and Department of Neonatal Education and Research, Masimo, Irvine, CA
†
Department of Pediatrics and Clinical Public Health, New York Medical College; and Maria Fareri Children’s Hospital at
Westchester Medical Center, Valhalla, NY
‡
Ibero-American Society of Neonatology (SIBEN)

Objectives After completing this article, readers should be able to:

1. Apply early pulse oximetry newborn screening to identify diseases

associated with neonatal hypoxemia.
2. Identify differences in screening protocols and algorithms.
3. Describe the impact of early detection of critical congenital heart defects
and hypoxemic neonatal conditions.

Abstract
Neonatal hypoxemia is sometimes difficult to detect. Therefore, it is
sometimes challenging to diagnose critical congenital heart defects and
other hypoxemic conditions before the infant becomes seriously ill.
Screening with pulse oximetry is a noninvasive and inexpensive valuable
method for early detection of these conditions. Establishing a protocol for all
newborns saves lives and decreases morbidity without increasing costs.

Education Gaps
AUTHOR DISCLOSURE Dr Sola has disclosed
that he is a part-time member of the Masimo
1. Normal neonatal saturation values in room air at sea level and at high
(Irvine, CA) speakers’ bureau. Dr Golombek
has disclosed that he is on the speakers’ altitude varies after the period of transition from fetal to neonatal life and
bureau of Mallinckrodt and a consultant with up to 48 hours of age.
Prolacta. This commentary does not contain a
discussion of an unapproved/investigative 2. Cyanosis is not a very reliable clinical sign to detect neonatal hypoxemia.
use of a commercial product/device.
3. Technology is available for evaluation and screening of neonatal
ABBREVIATIONS hypoxemia.
AAP American Academy of Pediatrics
CCHD critical congenital heart defects
PI perfusion index
PPHN persistent pulmonary hypertension INTRODUCTION
SET signal extraction technology
SIBEN Ibero-American Society of
Congenital heart disease is one of the most common types of birth defects, affect-
Neonatology ing approximately 8 in 1,000 live-born infants. Critical congenital heart defects
SpO2 pulse oximetry (CCHD), including ductal-dependent lesions, occur in 1 to 3 per 1,000 live births,

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 and account for about 40% of deaths associated with con-
genital malformations occurring in the first year of age. It is
estimated that 60% of neonatal deaths in the United States
are preventable. Neonatal hypoxemia is potentially fatal if
there is a delayed or missed diagnosis of CCHD, pneumonia,
sepsis, or persistent pulmonary hypertension (PPHN). Earlier
detection of these pathologic conditions leads to improved
management and outcomes. Numerous references sup-
port these statements but, for the purposes of providing an
overview, we have limited the number cited in this review.
The prevalence, epidemiology, and impact of delay in
the diagnosis of hypoxemic newborn diseases have been
described in several publications. (1)(2)(3)(4)(5)(6)(7)(8)
More than 30% of infant deaths associated with CCHD
have been attributed to a late or missed diagnosis, which
raises a concern for neonatal safety. (6) In Great Britain, it
was estimated that 25% of infants with CCHD were not
diagnosed until after discharge from the hospital when the
infant presented in critical condition. (9)(10)(11)(12) In
developing countries, it is estimated that more than half
of neonates with CCHD are diagnosed after the first week
of age. (13)(14)(15) It is now understood that routine prena-
tal imaging or physical examination of the neonate is insuf-
ficient for the early neonatal detection of potentially lethal
cardiac conditions and that the delay in diagnosis may in-
crease the risk of death or permanent injury.
This concern about delayed diagnosis of CCHD led to
exploring the value of early detection with pulse oximetry
(SpO2) monitoring. SpO2 is a noninvasive method that
allows for rapid measurement of saturation of hemoglobin in
arterial blood. It can detect hypoxemia in asymptomatic
newborns with severe health conditions. Pulse oximetry with
signal extraction technology (SET) is very easy to perform,
fast, noninvasive, and cost-effective, and has significantly
improved the quality and safety of neonatal health care. There
is currently sufficient evidence on the benefits of SpO2 CCHD
screening, and many organizations such as the US Advisory
Committee on Hereditary Diseases endorse this screening
test. (16)(17)(18)(19)(20) In 2015, the Centers for Disease
Control and Prevention (CDC) and the American Academy
of Pediatrics (AAP) convened an interdisciplinary panel with
the goal of learning about practices in the United States that
diagnose CCHD and identify opportunities for improve-
ments. Many of their recommendations were published in
April 2016 and are included in this review. (15)
A fetal anatomic survey with ultrasonography can identify
cardiac structural abnormalities; however, this detailed ultra-
sonographic method is operator-dependent and highly incon-
sistent. Prenatal detection of CCHD is highly variable. (21) In
1 recent report of more than 30,000 fetuses from Norway,
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only 57% of affected fetuses were identified prenatally. (22) In
some cases, the diagnosis of fetal CCHD is inaccurate, with
postnatal studies showing a different cardiac defect or a
structurally normal heart. Prenatal care and assessment is
also highly variable in different countries and repeated pre-
natal ultrasonography is impractical and costly.
In 2009, de-Wahl Granelli et al published a cohort study
of 39,821 newborns, which showed the impact of measuring
oxygen saturation with SpO2 in the upper and lower extrem-
ities. (23) This group used a monitor that properly measured
SpO2 despite motion and low perfusion. Ewer et al confirmed
the importance of using the same technology for early detection
of CCHD in 20,055 asymptomatic newborns; their study
showed the accuracy of this screening, even during the first
few hours after birth. (24) Zhao and colleagues in China
studied 100,000 newborns and demonstrated the same ben-
efit. (25) In January 2012, the AAP published recommenda-
tions, with the approval of the US Department of Health, to
perform oximetry to evaluate all newborns for CCHD. (16)(17)
(18) In addition to CCHD, several other serious hypoxemic
conditions can be diagnosed early with SpO2 screening.
This article will review the recommendations for early
SpO2 newborn screening to identify diseases associated with
neonatal hypoxemia. The information is obtained from all
the cited references and also from the IX Clinical Consen-
sus of the Ibero-American Society of Neonatology (SIBEN).
(15)(26) At SIBEN’s Annual 2016 Congress in Asunción,
Paraguay, 39 neonatologists and 4 neonatal nurses from 18
Ibero-American countries met and published the recommen-
dations listed herein.
The early evaluation of all newborns with SpO2 screen-
ing is a noninvasive, easy to perform, and low-cost method
that can be performed between 8 and 48 hours of age. It
has excellent clinical utility at detecting potentially serious
diseases in asymptomatic infants. The universal imple-
mentation of this evaluation in clinical practice enhances
cardiopulmonary assessment, increases patient safety, and
reduces morbidity, sequelae, and mortality.
WHAT ARE THE NEONATAL CONDITIONS FOR WHICH
DETECTION OF HYPOXEMIA WITH SPO2 CAN BE USEFUL
BEFORE SEVERE CLINICAL MANIFESTATIONS OCCUR?
The SpO2 screening test is very useful for the early detection
of neonatal conditions with hypoxemia. The specific cardiac
defects that can be detected and which require intervention
(ie, catheterization or surgery) during the first year of age
are listed in Table 1.
It is important to recognize that, in addition to congenital
heart disease, the following conditions can be identified with
 the time. These 2 SpO2 readings can be obtained consecutively
TABLE 1. Critical Heart Lesions Detected on with 1 monitor or simultaneously with 2 monitors.
Pulse Oximetry Screening
Pre- and Postductal SpO2 Differences
LEFT-SIDED LESIONS RIGHT-SIDED LESIONS
SpO2 screening requires both preductal and postductal mea-
Hypoplastic left heart Pulmonary atresia (intact septum surements to avoid an increase in false-negative and false-
syndrome or with a ventricular septal
defect) positive results. Newborns with obstruction of the left outflow
tract may not be diagnosed if a single-site measurement is
Interruption of the Pulmonary valve stenosis
aortic arch used. Ewer (12) and de-Wahl Granelli et al (27) also observed
Coarctation of the Tricuspid atresia
that both measurements increase the chances of early diag-
aorta, severe nosis of other serious hypoxemic conditions in the neonate.
Aortic valve stenosis Ebstein anomaly In healthy newborns without heart disease, the normal
Tetralogy of Fallot SpO2 value is usually greater than 94% in both locations and the
Transposition of the great vessels difference between the preductal and postductal measure-
Anomalous pulmonary venous
return
ments is minimal. In 1 study, oxygen saturations were mea-
Truncus arteriosus sured in 13,714 healthy newborns without cardiac or pulmonary
disease at a median age of 25 hours using SpO2 monitors with
SET, and with 8- to 10-second mean times and reusable probes.
SpO2 screening: 1) early sepsis, 2) congenital pneumonia, The preductal or postductal SpO2 was greater than or equal to
3) PPHN, 4) meconium aspiration, 5) transient tachypnea 95% in 99.5% of the infants, with the mean postductal SpO2
of the newborn, 6) pneumothorax, and 7) other less fre- value being higher than the preductal SpO2. (28) In 40% of
quent varied neonatal conditions. these infants, the postductal SpO2 value was higher than the
This method of screening is not a reliable indicator of preductal SpO2, with 38% having equal pre- and postductal
obstruction of the airway (eg, choanal atresia, dysfunction of SpO2 values and 22% with postductal SpO2 values that were
the vocal cords) because these airway lesions may be asso- lower than the preductal SpO2. However, any difference was
ciated with alveolar hypoventilation, with an elevated PaCO2 clinically insignificant, with a mean difference of only 0.29%.
but normal PaO2. However, if these newborns are hypox- The definition of a significant difference between pre-
emic, the SpO2 screening will also be abnormal. and postductal SpO2 during screening varies based on
the protocol chosen for screening. The recommendations
HOW SHOULD EARLY SPO2 SCREENING BE endorsed by the Secretary’s Advisory Committee on Heri-
PERFORMED? table Disorders in Newborns and Children of the USA, (16)
which are based on the protocol of de-Wahl Granelli et al
General Clinical Protocols (23) consider a difference of more than 3% to be significant.
Neonatal screening for the detection of pathologic condi- However, in the UK protocol, which is based on the studies
tions with hypoxemia has been used in clinical practice of Ewer et al, a difference of more than 2% was considered to
since 2011. Since then, studies and meta-analyses have be significant. (24) These differences are significant regardless
shown that such screening meets the criteria for a popula- of whether the preductal SpO2 value is higher than the post-
tion screening test. ductal SpO2 value or vice versa and even if both preductal
The SpO2 screening is an easy technique, and should be and postductal SpO2 measurements are normal (ie, >95%).
performed in all apparently healthy newborns between 12 and The differences in SpO2 measurements can occur with:
48 hours after birth or before discharge. (Note: the timing of the 1) a normal SpO2 (>95%) in both the right hand and 1 foot;
screening varies among protocols.) The clinician can perform 2) an abnormal SpO2 (<95%) in both extremities; and 3) an
this screen by placing 1 sensor in the palm of the newborn’s abnormal SpO2 in 1 territory (ie, preductal or postductal) but
right hand (preductal) and another sensor on 1 of the newborn’s normal in the other territory.
feet (postductal). For preductal measurements, all large inves- When the preductal SpO2 value is higher than the post-
tigations have placed the sensors on the palm and the US Food ductal SpO2 value, possible explanations include 1) obstructions
and Drug Administration has recommended palm placement to the left heart with a right-to-left ductal shunt, and 2) persistent
when using pulse oximetry monitors. Although the left hand PPHN of the newborn with a right-to-left ductal shunt.
may be used for a preductal measurement, it is not the pre- When the postductal SpO2 value is higher than the pre-
ferred site because it only reflects the preductal value 80% of ductal SpO2 value, possible reasons are 1) an error in the

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 monitor, or 2) transposition of the great vessels with a
conotruncal abnormality (eg, obstruction due to aortic
stenosis or an interrupted aortic arch).
In summary, a significant difference between pre- and
postductal values (>2% or >3%) indicates the presence of a
shunt at the ductal level, and points to an abnormality,
regardless of which of the 2 territories is higher. Of course,
there are abnormal cardiac conditions without a pre-/post-
ductal SpO2 difference; this occurs when the blood mixture
of deoxygenated and oxygenated blood (ie, “shunt”) occurs
mostly at other levels (eg, anomalous venous return, atrial
level, ventricular level) and there is very little or no shunt at
the ductal level. However, in these cases, the SpO2 is usually
less than 95%.
Technology for Screening
For accurate SpO2 screening, it is important to use equip-
ment that provides reliable results during motion and in
low perfusion situations; in addition, the technique should
show the pulsed wave signal and the perfusion index (de-
scribed later). de-Wahl Granelli et al, Ewer et al, and Zhao
et al showed that about 200,000 nurses (23)(24)(25) were
able to perform SpO2 screening using this technology without
difficulty. Interestingly, 1 study found that SpO2 screening
did not improve CCHD detection in 15,299 newborns (29);
however, the monitor used in this study did not have the
appropriate technology to obtain stable signals, which may
explain the negative results of this study.
Evaluating the quality of the SpO2 signal is fundamental
to correctly interpret the SpO2 reading; therefore, SpO2
screening should be performed with a monitor that is not
altered by movements or affected by low perfusion.
Interpretation of SpO2 Screening
The cumulative published experience to date may be insuf-
ficient to draw conclusions about the ideal SpO2 screening.
The 2 protocols previously mentioned agree in defining
the screen as abnormal or “fail” if either the preductal or
postductal SpO2 value is less than 90%. (24)(27) This result
would require prompt clinical evaluation by a pediatric
provider and transfer to a NICU. However, the protocols
differ in several areas: age at the time of screening; whether 1
or both territories need to be abnormal (defined as an SpO2
value of 90%–94%); the cutoff value that defines a signif-
icant pre-/postductal SpO2 difference (>2% or >3%); and
the number of times (once or twice) that an abnormal test
should be repeated in a healthy-appearing infant. Each of
these parameters is discussed below.
Age. The variability of published false-positive rates is
mostly related to the age at screening. Studies quoted in the
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list of references found that the false-positive rate is 0.035%
when the screening is done after 24 hours of age compared
with 0.9% in screenings performed at 4 to 6 hours of age
and 0.09% for screenings done at about 24 hours of age.
However, if the screening is planned for 24 hours of age or
later, some infants may become acutely ill before the
screening and the opportunity for early diagnosis is missed.
The current evidence seems to favor screening at about 12
hours of age or, at the latest, by 12 to 24 hours of age.
One or Both Territories. The US recommendation states
that both territories need to have an SpO2 reading of 90%
to 94% to be considered a “fail” result. Thus, a “pass” or
negative screening result could occur if only 1 territory has
an SpO2 level of greater than or equal to 95%. The UK
protocol, on the other hand, considers the screen abnormal if
either the hand or the foot has an SpO2 reading of 90% to 94%
and, therefore, a “pass” is designated only when both territories
have an SpO2 value greater than or equal to 95%.
Difference Between Pre- and Postductal Values. As men-
tioned before, there are different views about the definition
of an abnormal (ie, “fail”) SpO2 screening result. The pre-/
postductal SpO2 difference of greater than 2% is favored by
some authors. If this difference persists in 2 evaluations, the
infant should be assessed.
Repeating an Abnormal Screen Once or Twice. Some
clinicians firmly believe that if the SpO2 screening is abnor-
mal on 2 assessments, it is not appropriate to wait and repeat
a third screening test (as recommended by the US protocol)
in an asymptomatic newborn.
With the aforementioned caveats, the Fig summarizes 1
approach to CCHD screening in an asymptomatic newborn,
which is as performed in the UK based on the studies of Ewer
et al. (9)(10)(11)(12)(24) An infant with any symptoms for
cardiac, pulmonary, or infectious disease should be treated as
usual, without delays, regardless of the SpO2 screening result.
This protocol is based on the UK recommendations. If
the SpO2 is greater than or equal to 95% and there is a greater
than 2% difference, this would fit into the middle scenario
and the test should be repeated. The US protocol defines
an abnormal result if the pre-/postductal SpO2 difference is
greater than 3%. The US protocol also considers that it is not
necessary for both pre- and postductal values to be greater
than or equal to 95%; if only 1 of the SpO2 values is greater
than or equal to 95%, the infant ‘passes’ the screen. Also, the
US protocol considers that for an asymptomatic infant to fail
the screening evaluation, 3 test results need to be abnormal
and therefore the test needs to be repeated a 3rd time.
Preductal values are obtained from the right hand in all
screening protocols.
Figure. Protocol for screening an asymptomatic newborn at 12 to 24 hours of age or before discharge.

HOW SHOULD WE RESPOND TO AN ABNORMAL infants around the world who are born at altitudes higher
(POSITIVE) SPO2 SCREENING IN A CLINICALLY than 1,500 m (w4921 ft) above sea level. However, under-
WELL NEWBORN? standing cardiopulmonary physiology during fetal life and
the transition to extrauterine life, as well as the alveolar gas
The answer to this question is: Do not ignore an abnormal test
equation, can assist with establishing the best approach to
and humbly accept that we may be wrong in our clinical
these infants.
assessment. After an abnormal result, clinicians need to quickly
At the SIBEN clinical consensus meeting, (26) clinicians
evaluate the newborn with a detailed and complete examina-
reported that, on average, SpO2 values are not different in the
tion. Absence of a murmur, the presence of normal femoral
first 12 to 24 hours of age in infants born in locations less
pulses, or normal blood pressures does not rule out CCHD. In
than 2,500 m (w8,200 ft) above sea level. In a recent study,
addition, neonates with hypoxemia from noncardiac condi-
SpO2 was measured in newborns at 1,800 m (w5,905 ft)
tions may not have a murmur and the other parameters may
above sea level using a non–motion-resistant SpO2 monitor,
initially be normal. Unfortunately, there are legal cases in the
which has not been validated in neonates. (30) The 5% and
United States in which a positive (“fail”) test result was
95% range for SpO2 values reported in this study were about
“ignored,” and the infant later became critically ill or died.
90% and 98%, with mean and median preductal and
It is neither essential nor necessary to perform echocar-
postductal SpO2 values only slightly lower than those re-
diography in all infants with a “failed” screening SpO2 test.
ported at sea level. The SIBEN consensus statement and
In addition to careful observation, monitoring, and a detailed
others consider that at less than 2,500 m (w8,200 ft) above
physical examination, other studies may be needed to ensure
sea level, the same values as reported at sea level should
a timely and accurate diagnosis. A complete diagnostic
continue to be used until different well-established evidence
approach may include blood cell counts, cultures, a blood
becomes available.
gas, and chest radiography. Some newborns will require
At the recommended postnatal age for screening, the
echocardiography, and in some, it may be necessary to imme-
mean normal SpO2 value is lower at high altitudes (93%–
diately start an infusion of prostaglandin to maintain patency
96%), but with larger standard deviations. Therefore, if
of the ductus arteriosus (even before echocardiography).
screening is performed as recommended herein, the values
for positive and negative results for each asymptomatic
infant could be the same as the values at sea level, bearing
HOW DOES HIGH ALTITUDE INFLUENCE THE RESULTS
in mind that some newborns who are completely healthy
AND INTERPRETATION OF SPO2 SCREENING?
can have an SpO2 value of 91% to 94% at altitudes of more
Data are insufficient to clearly define generalizable normal than 2,700 m (w8,858 ft) above sea level. For these infants,
SpO2 levels within the first 24 hours after birth for the 7% of more detailed observation would be recommended, exercising

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 caution and avoiding aggressive investigations to prevent an
increase in the number of “false-positives.” Nevertheless,
precise cutoff points for SpO2 values in moderate and high
altitudes are not known to adequately balance sensitivity with
false-positive rates.
FALSE-POSITIVE AND FALSE-NEGATIVE SCREENING
As mentioned, an infant with a positive screening test has 1
SpO2 value less than 90% or 2 consecutive SpO2 values of
90% to 94% and/or a pre-/postductal difference greater
than 2%, based on the UK protocol. A false-positive result
occurs when additional testing after a positive screen finds
that the infant does NOT have any hypoxemic condition
such as CCHD, PPHN, transient tachypnea of the newborn,
sepsis, or meconium aspiration. This false-positive occur-
rence is extremely rare (<0.1%) if the screening method and
protocol are followed rigorously. If SpO2 screening is per-
formed before 12 hours of age, the false-positive rate is
slightly higher but the diagnosis of infectious and respira-
tory causes of hypoxemia are obtained earlier.
A false-negative result occurs when the SpO2 value is
normal (negative screening) but the infant is actually found
hours or days later to have a hypoxemic condition. Most
studies indicate that the most frequently undiagnosed
lesions are left-sided obstructed lesions with obstruction
to the outflow of the aorta (eg, coarctation of the aortic arch,
hypoplastic left heart, aortic stenosis), which are not nec-
essarily associated with hypoxemia. False-negative results
can also occur if the technology is inadequate. The use of the
preductal and postductal saturations, as described before,
and the perfusion index, described later, can be of some
value to improve detection but they are not infallible.
HOW SHOULD WE CARE FOR THE FAMILY OF A
NEWBORN WITH AN ABNORMAL OR POSITIVE
SCREENING RESULT?
In the first hours after birth, various events generate great
emotional tension. Health care professional should make
an effort to decrease this by all possible means. Families
should always actively participate in the care of their new-
born and they should also understand the rationale and
specifics of SpO2 screening.
Studies have shown that parents who are well informed
are mostly satisfied with SpO2 screening tests and perceive
screening to be a valuable method to identify sick newborns.
In addition, parents of neonates who had a false-positive
result did not show greater anxiety than those with negative
or normal screening results.
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It is recommended that parents receive written informa-
tion about the SpO2 screening test. This written information
must be accompanied by clear verbal communication and
clarification of any questions. If possible, the screening
should be performed with the parents present. If the new-
born passes the test, there will be no issue. However, if the
result is abnormal, parents may be shocked to receive this
information. As parents’ emotions change from joy to worry,
they may not be able to concentrate on the information that
is being discussed with them.
All members of the neonatal team (social workers,
nurses, nurse practitioners, and physicians) should be
trained to empathetically support parents of infants who
test positive on SpO2 screening. If the infant appears to be
completely healthy but the SpO2 screening result is abnor-
mal, clinicians should discuss with the parents the possi-
bility that this is a false-positive result.
Depending on the clinical situation, there may be a need
to proceed more or less quickly, but any communication
with families should occur in a calm and supportive way. It is
imperative to avoid delays while parents are processing the
information. Parental uncertainty while waiting for repeat
testing or further investigations can alter the relationship of
the parents with the infant, and disrupt breastfeeding and
maternal recovery. It is therefore especially important that
staff members performing these screening tests are pre-
pared in advance about how to communicate and empathize
with parents if the results are abnormal.
PERFUSION INDEX
Most studies report that the lesions most often missed on
SpO2 screening are those causing obstruction to aortic out-
flow (eg, hypoplastic left heart syndrome, critical aortic
stenosis coarctation, interrupted arch), which may not nec-
essarily be detected with antenatal ultrasonography, physical
examination, or abnormal SpO2 values. However, an addi-
tional SETpulse oximetry measurement may increase detec-
tion of CCHD caused by an obstruction to aortic outflow.
This measurement is called the perfusion index (PI), which
is an assessment of strength of perfusion at the monitored
site. A reference value was described for 10,000 newborns
with a median value of 1.70% and a fifth percentile of 0.70%.
(31) Granelli and Ostman-Smith showed that the addition of
an abnormal PI to SpO2 screening increases the sensitivity of
identifying CCHD with an obstruction to aortic outflow. (32)
However, adding the PI to the screening criteria may also
result in an increase in false-positive results.
The PI is normally higher than 0.70% in both preductal
and postductal territories. If it is less than 0.70% in 1
territory, the test should be repeated. After 3 abnormal re-
sults in a healthy infant, further evaluation is needed.
When the PI is less than 0.45%, it is indicative of low per-
fusion, which could be due to the aforementioned lesions. If
the PI is higher in the postductal territory, it could be due to
hypoplastic left heart syndrome or critical aortic stenosis with
right-to-left ductal shunting. In this case, the postductal SpO2
value will also be significantly lower than the preductal SpO2
value. On the other hand, if the preductal PI is higher than the
postductal value, one must consider a diagnosis of interrup-
tion of the aortic arch or coarctation of the aorta. More studies
are still needed, but a published review summarizes all aspects
of the PI in neonates (32) and a recent publication shows that
combining PI with SpO2 screening in nontertiary centers in-
creased the detection rate to 71%. (33) Furthermore, PIs were
measured using an automated data selection method in
healthy newborns during CCHD screening at 24 hours.
(34) The median PI in asymptomatic newborns 24 hours
after birth was 1.8 with a narrow interquartile range of 1.2
to 2.7. The median preductal PI was significantly higher
than the median postductal PI (1.9 vs 1.8, P¼.03) but this
difference may not be clinically significant.
DECREASE IN INFANT CARDIAC DEATHS
A study from December 2017 (35) shows that statewide im-
plementation of mandatory policies for newborn CCHD
screening was associated with a significant decrease in
infant cardiac deaths between 2007 and 2013 compared
with states without these policies. In the United States,
CCHD deaths dropped 16.8%, while other/unspecified
cardiac deaths dropped 13.2% after screening was instituted.
The authors also looked specifically at the 8 states that
implemented mandatory screening policies between August
2011 and June 2013. They found a 33.4% relative decrease in
CCHD deaths relative to previous years and other states, a
decrease of 3.9 deaths per 100,000 births. Deaths from other/
unspecified cardiac causes decreased 21.4% in states with
mandatory screening relative to other states, with an absolute
decline of 3.5 deaths per 100,000 births. (35) Therefore, the
evidence is now sufficient to declare newborn screening for
CCHD a successful public health intervention. Nearly all
states now have CCHD screening requirements for all term
infants who appear healthy and are asymptomatic.
WHAT TO DO WITH PRETERM INFANTS
The approach of SpO2 screening in preterm infants is a
somewhat separate issue, with individual provisos. If the
preterm infant seems healthy, is asymptomatic, and does
not require intensive care, screening should be conducted as
described here, within 6 to approximately 24 hours, without
delay or waiting for any specific postmenstrual age. On the other
hand, if the preterm infant is sick and is admitted to an inten-
sive care unit, the infant will have adequate continuous SpO2
monitoring and careful daily evaluations during the hospital

TABLE 2. Points to Remember About CCHD Screening

• CCHD is the most common birth defect, affecting approximately 8 in 1,000 live-born children; it is estimated that about 40,000 infants are born
with CCHD per year in the United States, and 1.35 million worldwide, including ductal-dependent lesions that affect between one-quarter and
one-third of these children.
• CCHD represents about 40% of deaths due to congenital malformations and most deaths from cardiovascular disease occurring in the
first year of age. Unfortunately, some neonatal deaths in more than 30% of infants with CCHD have been attributed to errors in diagnosis
or late diagnosis.
• The prenatal diagnosis of CCHD can improve perinatal outcomes for certain lesions. (45)(46) Recent evidence shows that prenatal detection of
CCHD has progressively increased from 2006 to 2012, but also that prenatal detection is highly variable.
• The prenatal diagnosis of CCHD can improve perinatal outcomes for certain lesions.
• Cyanosis is not a very reliable clinical sign to detect hypoxemia.
• The active approach of pulse oximetry with SET can achieve an improvement in the quality and safety of health care, as well as cost savings.
• Early diagnosis of CCHD in postnatal life significantly decreases morbidity and mortality rates.
• Early detection of CCHD and hypoxemic neonatal conditions not only reduces the suffering of children and families, but can also reduce
associated costs and long-term neurologic compromise by not delaying admission to a specialized care unit. Early diagnosis is also associated
with significant reductions in mortality, better surgical outcomes, less prolonged ventilation, and lower potential developmental problems.
• It is an obligation and responsibility of neonatal centers to improve care on a universal basis whenever possible, without waiting for laws or
bureaucratic processes that often place other interests above the needs of the newborns.

CCHD¼critical congenital heart defects; SET¼signal extraction technology.

Vol. 19 No. 4 APRIL 2018 e241

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 stay. In most infants, if not in all of them, diagnosis of CCHD is
likely to be made early in the infant’s course. However, if there
is any doubt, a complete screening should be performed
before discharge. Obviously, if complete echocardiography
has been performed, there is no need for SpO2 screening.
CONCLUSION
In summary, significant reductions in pediatric mortality,
better surgical outcomes, less prolonged ventilation, and
diminished potential developmental problems can occur if
hospitals adopt SpO2 screening in neonates for early and
timely detection of CCHD and other hypoxemic conditions.
(11)(15)(26)(27)(28)(36)(37)(38)(39)(40)(41)(42)(43)(44) Table 2
lists the most important factors to remember about SpO2
screening. Clinicians can use the specific SpO2 screening
protocol described herein or modify the approach to specific
scenarios (eg, elevated altitude). At the beginning of estab-
lishing a screening program for CCHD, each center must
use a clear protocol with a quality improvement process to
confirm that 100% of newborns are screened. The detection
of non-CCHDs and other disorders, such as respiratory
problems or early sepsis, should also be measured and
reported as an additional benefit. Physicians should be
aware that, even though the combination of early detection
with pulse oximetry and other methods of evaluation
reduces diagnostic errors, some infants might still be dis-
charged without a proper diagnosis. Most studies indicate
that the most frequently undiagnosed lesions are those that
cause obstruction to the outflow of the aorta (eg, coarctation
of the aortic arch), which are not necessarily associated with
hypoxemia. The use of the preductal and postductal satu-
ration difference and the PI improve detection rates, but
published studies have warned that this combined tech-
nique is also not infallible. The combined approach of using
SpO2 with SET, staff education, and a focus on family
support can lead to an improvement in the quality and
safety of health care for newborns along with lower asso-
ciated costs.
American Board of Pediatrics
Neonatal-Perinatal Content
Specifications
• Know how to interpret arterial blood gas measurements and
noninvasive methods for estimating arterial oxygenation.
• Know the indications, limitations, and techniques for newborn
screening for genetic disorders.
e242 NeoReviews
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 Screening with Pulse Oximetry for Early Detection of Neonatal Hypoxemia
Augusto Sola and Sergio G. Golombek
NeoReviews 2018;19;e235
DOI: 10.1542/neo.19-4-e235

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 Screening with Pulse Oximetry for Early Detection of Neonatal Hypoxemia
Augusto Sola and Sergio G. Golombek
NeoReviews 2018;19;e235
DOI: 10.1542/neo.19-4-e235

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