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[Heart murmur in children less than 2 years-old: looking for a safe and effective referral strategy]
Moisés Rodríguez-González1, Almudena Alonso-Ojembarrena1, Ana Castellano-Martínez1
1Unidad de Gestión Clínica de Pediatría, Sección de Cardiología Pediátrica, Hospital Universitario Puerta del Mar, Cádiz, España.
Insights
A new referral strategy for children under 2 with heart murmurs, using appropriate use criteria (AUC), safely identifies congenital heart disease (CHD) and reduces unnecessary echocardiograms.
Area of Science:
- Pediatric Cardiology
- Diagnostic Imaging
- Public Health
Background:
- Current Spanish guidelines recommend transthoracic echocardiography (TTE) for all children under 2 with heart murmurs.
- The American Pediatric Association developed appropriate use criteria (AUC) in 2014 to guide cost-efficient TTE use.
Purpose of the Study:
- To analyze AUC and clinical factors predicting congenital heart disease (CHD) in children under 2 with heart murmurs.
- To develop a safe and efficient referral strategy for pediatric cardiology.
Main Methods:
- A case-control study included 688 children under 2 referred for heart murmurs.
- Multivariate analysis identified predictors of CHD.
Main Results:
- 129 (19%) patients had CHD. Age < 3 months and fulfilling AUC predicted CHD.
- Concurrent infection and negative neonatal pulse oximetry screening reduced CHD risk.
- The proposed strategy showed 98% sensitivity and 99% negative predictive value, reducing TTE by 32%.
Conclusions:
- Referring children < 3 months old, meeting AUC, without concurrent infection, or with negative neonatal pulse oximetry screening is safe and efficient.
- This strategy effectively manages heart murmurs in young children.
- The approach optimizes resource utilization in pediatric cardiology.
Introduction:
Current guidelines in Spain recommend performing transthoracic echocardiography (TTE) in all children under 2 years of age with a heart murmur. In 2014, the American Paediatric Association published the first appropriate use criteria (AUC) for outpatient paediatric transthoracic echocardiography (TTE) to promote its cost-efficient use. The aim of this article is to analyse the AUC and other clinical factors as predictors of congenital heart disease (CHD) in children less than 2 years of age with a heart murmur, and to develop a safe and efficient referral strategy.
Patients And Method:
Case-control study conducted with children less than 2 years of age, referred from Paediatric Primary Care to Paediatric Cardiology during a 4-year study. A predictive model for CHD was determined using multivariate analysis.
Results:
A total of 688 patients were included, with 129 (19%) cases of CHD. An age less than 3 months (adjusted odds ratio [ORa] 3.8 [1.5-8.4], p=.030) and fulfilling AUC (ORa 16.3 [9.4-28.3], p<.001) were predictors of CHD. Concurrent infection (ORa 0.6 [0.2-0.8], p<.001) and a negative neonatal screening with pulse oximetry (ORa 0.1 [0.05-0.4], p=.001) decreased the risk of CHD. The referral strategy that included these criteria had a 98% sensitivity, 39% specificity, and positive and negative predictive values of 27% and 99%, respectively. It could not diagnose 2% of CHD (all mild), and showed a 32% TTE reduction rate compared to our current strategy.
Conclusion:
To refer children less than 3 months old, fulfilling AUC, without a concurrent infection, or without negative neonatal pulse oximetry screening, is a safe and efficient strategy for the management of heart murmur in children under 2 years of age.
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