Original article
Arch Dis Child Fetal Neonatal Ed: first published as 10.1136/archdischild-2019-317066 on 9 October 2019. Downloaded from http://fn.bmj.com/ on May 23, 2020 at Library Serials Dept.
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1
Department of Medicine Solna,
Clinical Epidemiology Unit,
Karolinska Institutet, Stockholm,
Sweden
2
Division of Obstetrics and
Gynecology, Department of
Women’s and Children’s Health,
Karolinska Institutet, Stockholm,
Sweden
3
Department of Clinical Science
and Education, Sodersjukhuset,
Karolinska Institutet, Stockholm,
Sweden
Correspondence to
Dr Maria Altman, Department
of Medicine Solna, Clinical
Epidemiology Unit, Karolinska
Institutet, Stockholm, Sweden;
​maria.​altman@​ki.​se
Received 17 February 2019
Revised 15 August 2019
Accepted 24 September 2019
© Author(s) (or their
employer(s)) 2019. No
commercial re-use. See rights
and permissions. Published
by BMJ.
To cite: Khammari Nystrom
F, Petersson G, Stephansson
O, et al. Arch Dis Child Fetal
Neonatal Ed Epub ahead of
print: [please include Day
Month Year]. doi:10.1136/
fetalneonatal-2019-317066
Khammari Nystrom F, et al. Arch Dis Child Fetal Neonatal Ed 2019;0:F1–F5. doi:10.1136/fetalneonatal-2019-317066
Diagnostic values of the femoral pulse palpation test
Fatine Khammari Nystrom,1 Gunnar Petersson,1 Olof Stephansson,1,2
Stefan Johansson,1,3 Maria Altman1
Abstract
Objectives To calculate diagnostic values of the
femoral pulse palpation to detect coarctation of the
aorta or other left-sided obstructive heart anomalies in
newborn infants.
Design Population-based cohort study.
Setting Stockholm-Gotland County 2008–2012.
Patients All singleton live-born infants without
chromosomal trisomies, at ≥35 gestational weeks,
followed-up until 1–2 years of age.
Main outcome measures Diagnostic values and ORs
for the femoral pulse test and subsequent diagnosis of
coarctation of the aorta or left-sided obstructive heart
malformation.
Results Among the 118 592 included infants, 432
had weak or absent femoral pulses at the newborn
examination. Seventy-eight infants were diagnosed with
coarcation of the aorta and 48 with other left-sided
obstructive heart malformations. The diagnostic values
for the femoral pulse palpation test to detect coarctation
of the aorta were: sensitivity: 19.2%, specificity: 99.6,
positive predictive value: 3.5% and negative predictive
value: 99.9%. For left-sided heart malformations:
sensitivity: 8.3%, specificity: 99.6%, positive predictive
value: 0.9% and negative predictive value: 100%.
Sensitivity for coarctation of the aorta increased from
16.7% when examined at <12 hours of age to 30.0% at
≥96 hours of age.
Conclusions The femoral pulse test to detect
coarctation of the aorta and left-sided heart
malformations has limited sensitivity, whereas specificity
is high. As many infants with life-threatening cardiac
malformations leave the maternity ward undiagnosed,
further efforts are necessary to improve the diagnostic
yield of the routine newborn examination.
Introduction
In many countries, newborn infants undergo a
routine physical examination before discharge
home. A major objective with this examination is
to identify congenital heart malformations where
timely treatment saves lives or reduces long-term
disability. However, despite the newborn exam-
ination, up to half of the congenital heart malfor-
mations are not diagnosed before discharge from
hospital.1–5 Of the undiagnosed heart malforma-
tions, some 20%–25% are critical.6 7 Congen-
ital coarctation of the aorta (CoA) accounts for
4%–6% of all congenital heart malformations.8–11
The malformation consists of a narrowing of the
descending aorta, typically located at the insertion
of the ductus arteriosus distal to the left subcla-
vian artery. CoA is difficult to detect with prenatal
screening methods.1 12 As symptoms usually appear
What is already known on this topic?
►► The newborn examination is designed to
identify congenital heart malformations where
timely treatment saves lives or reduces long-
term disability. However, coarcation of the aorta
and other left-sided heart malformations are
often missed at the examination or at pulse
oximetry screening.
What this study adds?
►► This is the first study calculating the diagnostic
values of the femoral pulse examination in a
population-based setting. The results show
that the femoral pulse examination has low
sensitivity, whereas specificity is high.
Protected by copyright.
after the first days of life or after closure of the
ductus arteriosus, CoA can easily be missed at the
routine newborn examination or pulse oximetry
screening during the postdelivery stay.13–18 Other
congenital left-sided obstructive heart malforma-
tions with similar haemodynamic consequences as
CoA, such as stenosis or atresia of the aortic valve,
are also frequently missed before discharge home.6 7
During the routine newborn examination, a
palpation of an absent or weak femoral pulse may
be a clinical sign of CoA or a congenital left-sided
obstructive heart malformation. Previous reports
have described a low sensitivity for the routine
newborn examination as a test to detect CoA.
However, these reports have been either small or
performed on selected populations.6 7 17 19 Based on
previous studies, we hypothesised that the femoral
pulse test sensitivity to detect CoA and left-sided
obstructive heart malformations in this large popu-
lation-based cohort would be lower than 50%.
Methods
Study design and data sources
We conducted a diagnostic population-based study
with historical data on infants born 2008–2012.
The data were prospectively collected at the time of
birth, at discharge home from maternal or neonatal
care and at follow-up 1–2 years later. We used data
obtained from the Stockholm-Gotland Obstetric
Database, the Swedish Neonatal Quality Registry
(SNQ), the Swedish National Patient Registry and
the Swedish National Cause of Death Registry. The
Stockholm-Gotland Obstetric Database contains
data from the medical record system Obstetrix,
   F1
 Original article
used for all maternity and delivery care in Stockholm-Gotland
counties, Sweden. The database includes maternal, delivery and
infant data on all births from 2008 to 2013.20 SNQ was created
in 2001 and includes data on all newborn infants treated in any
Swedish neonatal intensive care unit before 28 days of age. The
Swedish National Patient Registry (National Board of Health
and Welfare) includes all inpatient care and all hospital-based
outpatient care since 1987.21 The Swedish National Cause of
Death Registry (National Board of Health and Welfare) collects
data from 1961 and includes timing and cause of deaths of
Swedish citizens.22
Study population
The cohort included all 118 592 live-born singleton infants, with
a gestational age of 35 completed weeks or more and born in the
Swedish counties of Stockholm or Gotland, from 1 July 2008
to 31 December 2012. Stillbirths and infants with chromosomal
trisomies (International Classification of Disease, 10th Revision
(ICD-10): Q90-Q929) were excluded from the cohort, as were
infants with missing data on the newborn examination (n=419,
0.4%). Among the excluded infants due to missing data, two had
a diagnosis of CoA. Infants admitted for neonatal care usually
had a full examination at admission and always at discharge,
and therefore, these infants were also included in the study
population.
Exposures and outcomes
Exposure, or diagnostic test, was defined as the femoral pulse
examination, as registered in the Stockholm-Gotland Obstetric
Database. The result of the femoral pulse palpation was recorded
in a standardised manner on the routine newborn examination
as a binomial variable (normal or abnormal). Absent or weak
femoral pulse were defined as abnormal recordings. Outcome
was defined as the diagnosis of a prespecified disease or malfor-
mation, using the ICD-10 as registered in the Stockholm-Got-
land Obstetric Database; SNQ; the Swedish National Patient
Registry; and/or the Swedish National Cause of Death Registry
between 1 July 2008 and 31 December 2013. All infants were
followed up 1–2 years from birth. The following ICD-10 diag-
noses were defined as outcomes: congenital stenosis of the
aortic valve (Q230); congenital subaortic stenosis (Q244); CoA
(Q251); atresia of the aorta (Q252); stenosis of the aorta (Q253);
and other congenital malformations of the aorta (Q254). Since
CoA is the most common left-sided obstructive heart malforma-
tion, it was studied as a separate outcome.8 In the CoA group,
other heart malformations could also be present. The other diag-
noses were summarised into the compound outcome ‘other left-
sided obstructive heart malformations’. The Stockholm-Gotland
Obstetric Database provided data on gestational week, sex, age
at examination (hours), time and date of examination, results
of examination and repeat examinations (maximum three). In
Sweden, gestational age is determined by second trimester ultra-
sound in the vast majority of pregnancies, and gestational age is
calculated by last menstrual period only if ultrasound results are
unavailable.23 Pulse oximetry screening was routinely started in
the first 6 months of 2012 in Stockholm and Gotland.
Statistical analysis
Exposure status (femoral pulse examination result) was consid-
ered a diagnostic test, and outcome status (diagnosis or malfor-
mation) was used as the gold standard definition of disease.
Sensitivity, specificity and predictive values (positive and nega-
tive) including 95% CIs of separate examination tests were
F2 Khammari Nystrom F, et al. Arch Dis Child Fetal Neonatal Ed 2019;0:F1–F5. doi:10.1136/fetalneonatal-2019-317066
Arch Dis Child Fetal Neonatal Ed: first published as 10.1136/archdischild-2019-317066 on 9 October 2019. Downloaded from http://fn.bmj.com/ on May 23, 2020 at Library Serials Dept.
calculated (exact binomial test). To estimate possible effects of
timing on the diagnostic values, the results were stratified by
postnatal age at examination (<12; 12–<24; ≥24; ≥48; ≥72;
and ≥96 hours of age). In addition, risk of disease related to
findings at femoral pulse palpation, expressed by crude and
adjusted ORs with 95% CIs, was calculated by logistic regres-
sion. Gestational age, infant sex, birth weight for gestational age
according to the Swedish National Growth Chart24 and routine
newborn examination results from heart and lung auscultation
were a priori considered possible confounders and adjusted for
in a stepwise logistic regression. As sensitivity seemed to increase
over time in the stratified analyses of diagnostic values, we also
included postnatal age at investigation as a potential confounder.
A p value of <0.05 was considered statistically significant. All
analyses were performed with SAS V.9.4 Software.
Results
All included 118 592 infants had at least one registered routine
newborn examination, 34.7% had at least two and 3.8% had
three examinations registered in the data base. Median age was
32 (IQR 24–43) hours at first examination, 73 (IQR 56–95)
hours at second examination and 95 (IQR 72–129) hours at
third examination (table 1).
Seventy-eight infants (0.7‰) had CoA and 48 infants (0.4‰)
had other left-sided obstructive heart malformations at follow-up
(diagnosis positive), whereas the remaining 118 514 (99.9 %)
infants were considered ‘healthy’, that is, without a diagnosed
Protected by copyright.
CoA or any other left-sided obstructive heart malformation. The
cumulative incidence of CoA during the study period was 6.6/10
000 infants (78/118 592). The sex distribution was unequal with
60% males in the CoA group and 75% males in the left-sided
obstructive heart malformation group (table 1).
In 432 infants, femoral pulses were absent or weak at the
routine newborn examination (test positive). Fifteen of the 78
infants with CoA had a positive test at femoral pulse palpa-
tion (absent or weak femoral pulses) and 63 had a negative test
(normal femoral pulses) when including all performed examina-
tions. Sensitivity, specificity, positive predictive value (PPV) and
negative predictive value (NPV) are presented in table 2. Four
of the 48 infants with other left-sided obstructive heart malfor-
mations had a positive test. The diagnostic values are presented
in table 2. When analyses were based on the findings from the
first examination only, 10 infants who were later diagnosed
with CoA had a positive test and 68 had a negative test. The
sensitivity (95% CI) to detect CoA in the first examination was
12.8% (6.3% to 22.3%), specificity 99.7% (99.6%–99.7% to
100%), PPV 4.5% (1.3% to 5.0%) and NPV 99.9% (99.9% to
100%). For other left-sided obstructive heart malformations,
diagnostic values were the same regardless if analyses were based
on the first examination or all performed examinations (data not
shown).
Having a positive femoral pulse test was associated with a 67
times increased risk of having CoA. After adjustment for gesta-
tional age, sex and birth weight, OR was 60.3 (33.7 to 108.1).
After adjustments also for results on respiratory and heart
auscultation, OR decreased to 22.3 (11.7 to 42.3). Introducing
age at examination into the model did not change the results
significantly (data not shown). Having a positive femoral pulse
test was associated with a 25 times increased risk of having other
left-sided obstructive heart malformations. After adjustment
for age, sex and birth weight, OR was 23.5 (8.3 to 66.3). After
adjustments also for results on respiratory and heart ausculta-
tion, OR decreased to 7.1 (2.4 to 21.0, table 3).
 Original article

Arch Dis Child Fetal Neonatal Ed: first published as 10.1136/archdischild-2019-317066 on 9 October 2019. Downloaded from http://fn.bmj.com/ on May 23, 2020 at Library Serials Dept.
Table 1 Infant characteristics, births in Stockholm-Gotland counties, Sweden, 2008–2012
Infants with later diagnosis of
Infants without CoA or other left-sided obstructive Infants with later diagnosis of other left-sided obstructive heart
Total n=118 592 heart malformation n=118 466 CoA n=78 malformations* n=48
Gestational age, weeks
Number (%)
 35–36 3023 (2.6) 0 3 (6.1)
 37–41 108 167 (91.3) 76 (97.5) 43 (89.8)
 42+ 7276 (6.1) 2 (2.5) 2 (4.1)
Sex
Number (%)
 Female 57 717 (48.7) 31 (39.7) 12 (25.0)
 Male 60 746 (51.3) 47 (60.3) 36 (75.0)
Birth weight, grams 3559.4 (491.9) 3416.1 (487.8) 3422.4 (560.0)
Mean (SD)
Birth weight for gestational age, percentile
Number (%)
 <10th 7076 (6.0) 10 (12.8) 6 (12.5)
 10th–90th 98 165 (82.8) 61 (78.2) 39 (81.3)
 >90th 13 158 (11.1) 7 (9.0) 3 (6.3)
Apgar <7 at 5 min 714 (0.6) 1 (1.3) 0 (0.0)
Number (%)
Age at newborn examination in hours
Median (IQR)
 First examination 32.0 (24.0–43.0) 27.0 (15.0–44.0) 30.5 (21.5–43.5)
 Second examination 73.0 (56.0–95.0) 64.5 (48.5–91.5) 58.0 (40.0–89.0)
 Third examination 95.0 (72.0–129.0) 114.5 (92.0–145.0) 78.0 (71.0–88.0)

Protected by copyright.
Mortality 118 (0.1) 4 (5.0) 3 (6.1)
Number (%)
Age at death, days 116.0 (0–2317) 36.0 (4–194) 734.0 (226–1161)
Median (range)
*Congenital stenosis of aortic valve (Q230), congenital subaortic stenosis (Q244), atresia of aorta (Q252), supravalvular aortic stenosis (Q253) and other congenital
malformations of aorta (Q254).
CoA, coarctation of the aorta.

Analyses stratified by postnatal age at examination showed
that the performance of femoral pulse palpation test to detect
CoA may change with increasing age. From <12 hours to ≥96
hours after birth, sensitivity increased from 16.7 to 30.0, and
PPV increased from 2.8 to 8.8. However, overlapping 95% CIs
indicated that there was no statistically significant difference
between the groups. Specificity and NPV were similar over time
(figure 1 and online supplementary table 1).
Discussion
As the first large population-based study with prospectively
collected data, we report that only 19.2% of infants with
isolated CoA were diagnosed by the femoral pulse palpation
during the routine newborn examination. However, almost
100% of infants with normal femoral pulses at examination
were correctly identified as not having CoA. For other left-sided
obstructive heart malformations, the diagnostic features of the
femoral pulse palpation test showed a similar pattern. In our
regression analyses, respiratory and cardiac status confounded
the association between femoral pulse test and the risk of CoA
and other left-sided obstructive heart malformations.
The major strengths of this study are the inclusion of a large
population-based cohort and a prospective data collection.
Furthermore, this is the first study to provide risk estimates
adjusted for important confounders and the first to present diag-
nostic values at increasing postnatal age at examination. Limita-
tions include a possibility of information bias, as we have used
register data to define both exposure and outcome. However,
Khammari Nystrom F, et al. Arch Dis Child Fetal Neonatal Ed 2019;0:F1–F5. doi:10.1136/fetalneonatal-2019-317066
any misclassification of exposure are likely independent of
outcome and should be considered non-differential. Second, we
had no information about prenatal diagnostics and no data on
the timing of diagnosis of cardiac malformation. We cannot rule
out the possibility that some infants were already diagnosed with
a CoA or other left-sided obstructive heart malformations before
the routine newborn examination was performed. Already diag-
nosed infants would have a higher probability of a positive test,
which would exaggerate sensitivity. However, antenatally diag-
nosed infants would probably be on prostaglandin treatment to
keep the ductus arteriosus open, which would underestimate
sensitivity of the test. Also, CoA has been reported to be one of
the least likely heart malformations to be diagnosed by antenatal
ultrasound.1 12 Third, we have followed up the infants until 1–2
years of age. Mild coarctation might develop some time after
birth, and these cases would be missed in the neonatal screening
but possibly have a diagnosis before 2 years of age. In this case,
our results would be diluted and sensitivity would be under-
estimated. Fourth, pulse oximetry screening was not routinely
implemented in the geographic area until mid-2012, and we did
not have data on pulse oximetry tests in our cohort. The pulse
oximetry screening is an important method to detect cyanotic
heart malformations, but it is not the best test to detect coarcta-
tion or left-sided heart defects because they are not necessarily
cyanotic. Fifth, we had to exclude 419 infants due to missing data
on the femoral pulse test. Two of these had a diagnosis of coarc-
tation. We do not know why these infants did not have an exam-
ination recorded, and the missing data may have introduced bias
F3
 Original article

Arch Dis Child Fetal Neonatal Ed: first published as 10.1136/archdischild-2019-317066 on 9 October 2019. Downloaded from http://fn.bmj.com/ on May 23, 2020 at Library Serials Dept.
Table 2 Diagnostic and predictive values for femoral pulse
palpation’s ability to detect coarctation of the aorta* and other left-
sided obstructive heart malformations†
Diagnosis No diagnosis Total
Coarctation of the aorta
 Positive test 15 417 432
 Negative test 63 118 097 118 160
 Total 78 118 514 118 592
Other left-sided obstructive heart malformations
 Positive test 4 428 432
 Negative test 44 118 116 118 160
 Total 48 118 544 118 592

Diagnostic and predictive values Value % 95% CI

Coarctation of the aorta
 Sensitivity 19.2 11.1 to 29.7
 Specificity 99.6 99.6 to 99.7 Figure 1 Diagnostic values of coarctation of the aorta, stratified by
 Positive predictive value 3.5 2.0 to 5.7 postnatal age at examination. SENS, sensitivity; PPV, positive predictive
 Negative predictive value 99.9 99.9 to100.0 value.
Other left-sided obstructive heart malformations
 Sensitivity 8.3 2.3 to 20.0
study adds new and important data for the clinician who exam-
 Specificity 99.6 99.6 to 99.7
ines newborn infants on a daily basis.
 Positive predictive value 0.9 0.3 to 2.4 A timely diagnosis of congenital heart malformation is
 Negative predictive value 100.0 100.0 to 100.0 important to prevent short-term and long-term morbidity and
Positive test means that femoral pulse was weak or absent in the newborn mortality.11 27 31 The examining doctor should be aware of the
screening examination, regardless if an infant was examined one or several times. low sensitivity for CoA when palpating the femoral pulses and

*ICD-10: Q251.
†ICD-10: Q230; Q244; Q252; Q253; and/or Q254.
ICD-10, International Classification of Disease, 10th Revision.
into the study. Last, although suggested by increasing sensitivity
with higher postnatal age, we did not have sufficient power in
this study to detect a statistically significant difference between
examinations at different ages.
In this population-based cohort, we had a slightly higher
incidence of CoA, compared with other studies. This discrep-
ancy may be caused by different populations, countries and
definitions of CoA. Our results confirm previous findings that
the routine newborn examination is an insufficient screening
test for CoA and other left-sided obstructive heart malforma-
tions.1 6 17 25–30 We hypothesised that sensitivity would be below
50%, which seemed a plausible number based on the literature.
However, earlier studies have been either small-sized or studied
the routine newborn examination as a whole without separating
the different examination steps, and none before us have calcu-
lated odds, adjusted analysis for important confounders or put
the results on a time scale of infant age at examination. We found
that sensitivity is as low as 20% and we believe that the present
Protected by copyright.
be attentive for other clinical signs suggesting a cardiac disease.
The high specificity and NPV indicate that the femoral pulse test
is reliable for excluding CoA. Nevertheless, it is important to
understand how the relative improbability of CoA in an unse-
lected population of newborn infants affects the numbers. At any
test result, the risk of CoA is minimal, and our results show that
a negative test could be a false assurance because 81% of infants
later diagnosed with CoA had a negative femoral pulse test.
Suggestions for future research would be diagnostic studies
also including results of pulse oximetry and perfusion index
screening to study the possible effects on sensitivity.32 Further
research should also investigate the effects of postnatal age on
the diagnostic values of the newborn screening examination.
The overall aim must be to find a method that would detect
CoA and left-sided heart malformations before the closure of the
ductus arteriosus.
Conclusion
Our results show that the femoral pulse examination detects
only 19.2% of CoA cases in an unselected infant popula-
tion. The corresponding result for other left-sided obstructive
heart malformations are 8.3%. Even though the femoral pulse

Table 3 Association between femoral pulse palpation and risk of disease

Test result (femoral pulse palpation) Crude OR 95% CI Adjusted* OR 95% CI Adjusted† OR 95% CI
Coarctation of the aorta
 Positive test‡ 67.4 38.1 to 119.4 60.3 33.7 to 108.1 22.3 11.7 to 42.3
 Negative test 1.00 reference 1.00 reference 1.00 reference
Other left-sided obstructive heart malformations
 Positive test‡ 25.1 9.0 to 70.1 23.5 8.3 to 66.3 7.1 2.4 to 21.0
 Negative test 1.00 reference 1.00 reference 1.00 reference
*Adjusted for gestational age, sex and birth weight for gestational age.
†Adjusted for gestational age, sex, birth weight for gestational age and results on respiratory and heart status in newborn clinical examination.
‡Absent/weak femoral pulse.

F4 Khammari Nystrom F, et al. Arch Dis Child Fetal Neonatal Ed 2019;0:F1–F5. doi:10.1136/fetalneonatal-2019-317066

examination has limited sensitivity, it is an important and quick
examination to detect some of the infants with CoA. Given that
a missed diagnosis could lead to major disability or even death,
we need to find alternative methods to improve the routine
newborn examination as a screening test for coarctation and
other left-sided congenital heart malformations.
Contributors FKN, MA, SJ and OS designed the study. GP programmed the
dataset. FKN and MA analysed the data. FKN performed the literature search and
wrote the first draft of the manuscript. SJ, OS, GP and MA redrafted the manuscript.
MA was the guarantor of the study, was responsible for the work and controlled the
decision to publish. All authors approved the final manuscript before submission.
Funding FKN was supported by the Foundation of Samaritan, the Freemasons
Foundations House of Children and the Foundation of Sven Jerring. MA was
supported by the Stockholm City Council. OS was supported by the Swedish Research
Council (523-2013-2429), the Swedish Research Council for Health, Working Life
and Welfare (2015-00251), Stockholm City Council and the Strategic Research
Program in Epidemiology at Karolinska Institutet. All authors are independent from
their funding sources and all had full access to the data and take full responsibility
for the integrity of the data and the accuracy of the data analysis.
Disclaimer None of the funding sources had any role in the study design,
collection, analysis or interpretation of data, nor in the writing of the manuscript or
the decision to submit for publication.
Competing interests None declared.
Patient consent for publication Not required.
Ethics approval Approval was obtained from the Regional Ethical Review Board in
Stockholm (reference numbers 2009/275-31 and 2014/177-32).
Provenance and peer review Not commissioned; externally peer reviewed.
Data availability statement Data are available on reasonable request, after a
renewed ethics approval.
References
1 Lannering K, Bartos M, Mellander M. Late diagnosis of coarctation despite prenatal
ultrasound and postnatal pulse oximetry. Pediatrics 2015;136:e406–12.
2 Knowles R, Griebsch I, Dezateux C, et al. Newborn screening for congenital heart
defects: a systematic review and cost-effectiveness analysis. Health Technol Assess
2005;9:1–152.
3 Bakr AF, Habib HS. Combining pulse oximetry and clinical examination in screening for
congenital heart disease. Pediatr Cardiol 2005;26:832–5.
4 Ainsworth S, Wyllie JP, Wren C. Prevalence and clinical significance of cardiac murmurs
in neonates. Arch Dis Child Fetal Neonatal Ed 1999;80:F43–F45.
5 Wren C, Richmond S, Donaldson L. Presentation of congenital heart disease in
infancy: implications for routine examination. Arch Dis Child Fetal Neonatal Ed
1999;80:F49–F53.
6 Wren C, Reinhardt Z, Khawaja K. Twenty-Year trends in diagnosis of life-threatening
neonatal cardiovascular malformations. Arch Dis Child Fetal Neonatal Ed
2008;93:F33–F35.
7 Mellander M, Sunnegårdh J. Failure to diagnose critical heart malformations in
newborns before discharge--an increasing problem? Acta Paediatr 2006;95:407–13.
8 Bjornard K, Riehle-Colarusso T, Gilboa SM, et al. Patterns in the prevalence of
congenital heart defects, metropolitan Atlanta, 1978 to 2005. Birth Defects Res A Clin
Mol Teratol 2013;97:87–94.
Khammari Nystrom F, et al. Arch Dis Child Fetal Neonatal Ed 2019;0:F1–F5. doi:10.1136/fetalneonatal-2019-317066
Original article
Arch Dis Child Fetal Neonatal Ed: first published as 10.1136/archdischild-2019-317066 on 9 October 2019. Downloaded from http://fn.bmj.com/ on May 23, 2020 at Library Serials Dept.
9 Reller MD, Strickland MJ, Riehle-Colarusso T, et al. Prevalence of congenital heart
defects in metropolitan Atlanta, 1998-2005. J Pediatr 2008;153:807–13.
10 Hoffman JIE, Kaplan S. The incidence of congenital heart disease. J Am Coll Cardiol
2002;39:1890–900.
11 Abu-Harb M, Hey E, Wren C. Death in infancy from unrecognised congenital heart
disease. Arch Dis Child 1994;71:3–7.
12 Chew C, Halliday JL, Riley MM, et al. Population-Based study of antenatal detection
of congenital heart disease by ultrasound examination. Ultrasound Obstet Gynecol
2007;29:619–24.
13 Mawson IE, Babu PL, Simpson JM, et al. Pulse oximetry findings in newborns with
antenatally diagnosed congenital heart disease. Eur J Pediatr 2018;177:683–9.
14 Thangaratinam S, Brown K, Zamora J, et al. Pulse oximetry screening for critical
congenital heart defects in asymptomatic newborn babies: a systematic review and
meta-analysis. The Lancet 2012;379:2459–64.
15 de-Wahl Granelli A, Wennergren M, Sandberg K, et al. Impact of pulse oximetry
screening on the detection of duct dependent congenital heart disease: a Swedish
prospective screening study in 39,821 newborns. BMJ 2009;338:a3037.
16 Richmond S, Reay G, Abu Harb M. Routine pulse oximetry in the asymptomatic
newborn. Arch Dis Child Fetal Neonatal Ed 2002;87:83F–8.
17 Abu-Harb M, Wyllie J, Hey E, et al. Presentation of obstructive left heart malformations
in infancy. Arch Dis Child Fetal Neonatal Ed 1994;71:F179–F183.
18 Strafford MA, Griffiths SP, Gersony WM. Coarctation of the aorta: a study in delayed
detection. Pediatrics 1982;69:159–63.
19 Zuppa AA, Riccardi R, Catenazzi P, et al. Clinical examination and pulse oximetry as
screening for congenital heart disease in low-risk newborn. J Matern Fetal Neonatal
Med 2015;28:7–11.
20 Altman M, Sandström A, Petersson G, et al. Prolonged second stage of labor is
associated with low Apgar score. Eur J Epidemiol 2015;30:1209–15.
21 The National patient register: the National board of health and welfare. Available:
http://www.​socialstyrelsen.​se/​register/​halsodataregister/​patientregistret [Accessed 28
Mar 2018].
22 The Swedish national cause of death registry: the National board of health and
welfare;. Available: http://www.s​ ocialstyrelsen.​se/​register/​dodsorsaksregistret
Protected by copyright.
[Accessed 2018-03-28].
23 Høgberg U, Larsson N. Early dating by ultrasound and perinatal outcome. A cohort
study. Acta Obstet Gynecol Scand 1997;76:907–12.
24 Marsál K, Persson PH, Larsen T, et al. Intrauterine growth curves based on
ultrasonically estimated foetal weights. Acta Paediatr 1996;85:843–8.
25 Ewer AK. Screening for critical congenital heart defects with pulse oximetry: medical
aspects. Am J Perinatol 2016;33:1062–6.
26 Prudhoe S, Abu-Harb M, Richmond S, et al. Neonatal screening for critical
cardiovascular anomalies using pulse oximetry. Arch Dis Child Fetal Neonatal Ed
2013;98:F346–F350.
27 Schultz AH, Localio AR, Clark BJ, et al. Epidemiologic features of the presentation
of critical congenital heart disease: implications for screening. Pediatrics
2008;121:751–7.
28 Chang R-KR, Gurvitz M, Rodriguez S. Missed diagnosis of critical congenital heart
disease. Arch Pediatr Adolesc Med 2008;162:969–74.
29 Kuehl KS, Loffredo CA, Ferencz C. Failure to diagnose congenital heart disease in
infancy. Pediatrics 1999;103:743–7.
30 Meberg A, Otterstad JE, Frøland G, et al. Early clinical screening of neonates for
congenital heart defects: the cases we miss. Cardiol Young 1999;9:169–74.
31 Meberg A, Lindberg H, Thaulow E. Congenital heart defects: the patients who die.
Acta Paediatr 2005;94:1060–5.
32 Schena F, Picciolli I, Agosti M, et al. Perfusion index and pulse oximetry screening for
congenital heart defects. J Pediatr 2017;183:74–9.
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