Infants with critical congenital heart disease who are born in hospitals with lower-level nurseries are at higher risk for missed diagnosis, researchers have found.

Among newborns with CCHD, late detection rates were higher among those born in hospitals with level I and II nurseries than for those born in hospitals with level III nurseries (37% and 26% vs. 17%), April Dawson, MPH, of the CDC’s National Center on Birth Defects and Developmental Disabilities in Atlanta, and colleagues reported in Pediatrics

“Thus, perhaps universal newborn screening for CCHD could be particularly beneficial in level I and II nurseries and may reduce differences in the frequency of late diagnosis between birth hospital facilities,” the researchers wrote.

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The U.S. Department of Health and Human Services first recommended universal CCHD screening with pulse oximetry in 2010, and results from a recent study in New Jersey, where CCHD screening is currently mandated, suggest the program has been successful. But concerns about resources constraints pose challenges to implementation.

Newborns with CCHD who leave the hospital without a diagnosis are at greater risk for cardiovascular collapse or death. To better understand the factors that may contribute to late diagnosis, Dawson and colleagues examined data on 3,605 infants born from January 1998 through December 2007 who were included in the Florida Birth Defects Registry. Infants had one of 12 specific types of CCHD with primary or secondary targets for pulse oximetry screening.

Primary targets included those always or most always present with hypoxemia including dextro-transposition of the great arteries, truncus arteriosus, total anomalous pulmonary venous connection, tricuspid atresia, pulmonary artresia with intact septum, hypoplastic left heart syndrome and tetralogy of Fallot.

Secondary targets included “defects that sometimes present with hypoxemia,” including double-outlet right ventricle, Ebstein anomaly, coarctation/hypoplasia of the aortic arch, aortic interruption/atresia/hypoplasia and single ventricle.

Overall, 22.9% had their CCHD detected late, after the birth hospitalization. The most common condition among those with late diagnosis was coarctation/hypoplasia of the aortic arch (33.3%).

Nursery level at the birth hospital and specific CCHD condition were the strongest predictors of late detection in a multivariate analysis.

Greater use of pulse oximetry and other diagnostic tools in higher level nurseries may explain the results, the researchers hypothesized. “However, routine pulse oximetry screening practices are focused on detecting CCHD conditions in asymptomatic newborns, who are unlikely to be admitted to higher-level nurseries before diagnosis.”

Another possible explanation is that level III nurseries may detect more CCHD due to higher rates of prenatal diagnosis and better clinical awareness compared with community hospitals. “Thus the greatest benefit to newborn CCHD screening may accrue to infants born in community hospitals,” the researchers wrote.

The study had several limitations including inability to control for prenatal heart defect diagnosis, use of hospital-wide indicators of nursery level instead of information from specific nurseries where infants received care, lack of information on length of stay during the birth hospitalization, and inability to generalize the findings to other states.


  1. Dawson A et al. Pediatrics 2013; doi: 10.1542/peds.2013-1002.