Should Dual Pulse Oximetry Screening Be Used in Neonates? The Insights from the CHOOSE Study

Critical congenital heart disease (CCHD) is a leading cause of neonatal morbidity and mortality. Early detection is crucial to prevent life-threatening complications. Pulse oximetry screening (POS) is a noninvasive method to identify hypoxemia indicative of CCHD, but the optimal timing for screening remains debated.

To evaluate the diagnostic accuracy of dual POS performed at 24-36 h and 48-72 h of life for early detection of CCHD in neonates.

This prospective observational study was conducted over 20 months at a tertiary care neonatal intensive care unit (NICU) in India. A total of 1431 neonates, including term and preterm, underwent POS at two time points. Screening followed the modified American Academy of Pediatrics algorithm, with echocardiographic follow-up for positive screens. Sensitivity, specificity, positive predictive value, and negative predictive value (NPV) were calculated.

Of the enrolled neonates (n = 1431), dual screening identified 95 positives (6.64%): 11 CCHD, 38 noncritical CHD and 46 noncardiac hypoxemic conditions. Dual POS had higher sensitivity (73.33% vs. 60%) and NPV (99.7% vs. 99.54%), and a lower false-negative rate (26.66% vs. 40%). POS 2 detected 2 additional CCHDs missed by POS1. Among 1336 negatives, clinical follow-up found 4 CCHDs.

Dual POS significantly improves CCHD detection over single screening while identifying treatable noncardiac hypoxemic conditions. This nurse-led protocol is feasible even in resource-constrained NICUs, warranting routine adoption alongside clinical examination to minimize missed diagnoses of CCHD.