1. Management of a heart murmur in an asymptomatic neonate using a standardized approach
Levine RA, DO. Miladinovic B, PhD. Nardell K, MD. Galas J, MD. Balakrishnan M, MD.
INTRODUCTION
RESULTS
Provider impression
of murmur
CCHD (N=13)
n (%)
Correct: 0
(0%)
PPS (N=61)
Correct: 10 (16%)
PDA (N=53)
Correct: 95 (62%)
VSD (N=31)
Correct: 10 (32%)
PFO (N=293)
Correct: 44 (15%)
Congenital heart disease (CHD) is the most common birth defect in the USA.
Newborns murmur evaluations are costly & extensive with low likelihood of diagnosing critical congenital heart disease (CCHD).
AAP defines CCHD as cardiac lesions requiring surgical/catheter intervention within the 1st year of life.
There is no consensus on appropriate evaluation of a murmur in asymptomatic newborns.
Provider impression was documented in 264 of 303 infants w/murmur evaluation
Many infants had more than 1 cardiac lesion reported by echo
Reason for exclusion n
Murmur absent
≥24 hours
399
Evaluation <24 hours 43
Genetic syndrome 11
Abnormal fetal echo 9
Echo ± EKG not done
Murmur evaluation
>5 days 1
Demographics
Follow-up
n=290
CCHD
n=13
Female
n (%)
 136 (46.9)
 10 (76.9) GA
wks (range)
39 2/7 (35-41)
39 2/7 (36-40) BW
kg (range)
3.48 ( )
3.56 ( )
Maternal age
years (range)
28 (15-43)
30 (20-38)
Medicaid n (%)
 209 (73.1)
10 (76.9)
Prenatal care
281 (98.2)
12 (92.3)
TGH deliveries: 5,666
(8/2012-8/2013)
Asymptomatic newborns with murmur: 775
CCHD: 13
Required NICU admission*: 4
Required immediate intervention: 2
Required intervention in 1st year of life: 2
Newborn Nursery: 9
No CCHD,
requires outpatient cardiology follow-up: 289
Normal echo: 1
Excluded: 472
OBJECTIVES
Only 35% of
murmurs were accurately diagnosed by newborn nursery providers.
In asymptomatic newborns with murmurs:
Describe the problem with working up all asymptomatic newborns with a heart murmur
Develop a screening algorithm for these newborns prior to hospital discharge
Preform a cost analysis using our current guidelines prior to implementation of an algorithm.
ESTIMATED COST ANALYSIS
Total infants w/murmur evaluation: 303
Total infants w/evaluation made outside of guideline recommendations: 43
Family history of risk factors
Follow-up
N= 290 (%)
CCHD
N=13 (%) OR
(95%CI)
p-value
Cardiotoxic meds (n=251*)
7 (2.9)
2 (16.7)
6.62
( )
0.03
Drowning (n=253*)
 0 (0)
1 (8.3) NA
0.04
The following risks were not significant with p-value >0.05: IDM, Twin to twin transfusion syndrome, genetic syndrome, CHD, arrhythmia, cardiomyopathy, SIDS, sudden cardiac death, seizures, drowning
*n represents number of times risk factor documented in total N
* 3 of 4 NICU admissions had a positive pulse oximetry screen
METHODS
Test
Cost per test
Total cost
(n=303)
Potential cost savings
(n=43)
Pulse ox screen probe1 $7
$2,121
$301
EKG2
$450
$136,350
$19,350
Echo & doppler2
$3,909
$1,184,427
$172,000
Approximate total cost
$1,322,898
$191,651 3
Prospective observational study
Tampa General Hospital (TGH) ~5,500 births per year
Study period: 8/2012 to 8/2013
Develop electronic medical record (EMR) template
for cardiac history, clinical symptoms, & physical exam
Current TGH/USF Newborn Nursery guidelines for any newborn murmur: cardiac history, physical exam, blood pressure (4 extremity), pulse oximetry screening, EKG, Echo, ± Pediatric cardiology consult
PROPOSED ALGORITHM
Inclusion criteria
Exclusion criteria
GA ≥ 35 0/7 wks
BW ≥ 2 kg
1 to 5 days of life
Asymptomatic
Admitted to TGH’s newborn nursery
Murmur diagnosis by Pediatrician or Nurse practitioner
Fetal echo w/CHD
Genetic/metabolic syndrome
No EKG AND echo
General exam findings
Follow-up
N= 290 (%)
CCHD
N=13 (%) OR
(95%CI)
p-value HR
(>140 bpm)
 102 (35.2)
 9 (69.2)
4.15
( )
0.02
RR (>60)
8 (2.8)
2 (15.4)
6.4
( )
0.03
The following cardiac exam findings were not significant with a
p-value >0.05: feeding difficulty, color, blood pressure (upper extremity vs. lower extremity)
1 Pulse ox costs from CDC statistics
2 Echo/EKG costs from TGH statistics
CONCLUSIONS
There is difficulty in distinguishing benign newborn murmurs from those of CCHD and determining appropriate follow-up in the newborn nursery
An algorithm for asymptomatic newborns with a murmur can be developed
Preliminary cost analysis using this algorithm shows significant cost savings.
EMR template implementation resulted in >85% compliance and completion of documentation for cardiac history, clinical symptoms, & physical exam.
Future direction: Implement the developed algorithm at TGH and evaluate utility & cost-effectiveness.
Cardiac exam findings
Follow-up
N= 290 (%)
CCHD
N=13 (%) OR
(95%CI)
p-value
Grade (≥3/6 ) (n=293*)
 15 (5.4)
3 (23.1)
5.3 ( )
0.03
The following newborn general findings were not significant with a p-value >0.05: S1/S2, timing, radiation, quality
*n represents number of times finding documented in total N
Newborn nursery providers determined appropriate follow-up in 94% of infants, however they were incorrect for all diagnosed w/CCHD.
CONTACT: Dr. Rebecca Levine.
University of South Florida, Department of Pediatrics, Division of Neonatology, 1 Tampa General Circle, Room F170, Tampa, FL