1. Recognition & referral in the periphery SC Brown Division Pediatric Cardiology Department of Pediatrics & Child Health University of the Free State Bloemfontein

2. Introduction “the true test of a civilization is how well it protects it’s vulnerable and safeguards its future” (UNICEF) children vulnerable future understand need for cardiac services being done & needs to be done - growing need heart health

3. Epidemiology: CHD incidence of CHD 4- 12/1000 live births 50% severe – intervention 35% of ALL congenital defects CHD accounts for 50% of all deaths from malformations 10% of all deaths in first year of life

4. Epidemiology: Rheumatic fever prevalence developing countries: 1.2/1000 4.5 /1000 Africa SA ?? implications Rheumatic heart disease = continuing burden

5. Incidence ARF & prevalence RHD in Aboriginal Australians – Dpt of Health and community services, Northern Autralia Prevalence RHD per 1000 Incidence of ARF per 1000 < 55-1415-2425-34> 34 15 35 200 400 RHD 2003 ARF 2002

6. Burden of Pediatric Heart Disease: South Africa: prevalence 2004 SA population: 42,7 mil % children < 16: 6 834 965 RHD7 518 CHD8 885 both 16 403 Children’s Heartlink Review of WHO data HIV – exposed & infected ??

7. Key causes of Pediatric Heart disease in developing countries poverty and environmental risks drive poor nutrition and genetic weakness infectious diseases: rheumatic, TB, viral during pregnancy poor maternal and pharma care poor infant care obesity and inactivity (Children’s Heartlink Global Web survey, July 2004)

8. Why is early recognition important? clinical presentation & deterioration suddenly early death Baltimore-Washington Infant study 18% died < 1yr 9.6% of fatal cases not diagnosed < death avoid irreversible changes cost effective unrecognized CHD carries serious risk avoidable mortality & morbidity 24% sent home as normal ( Belgium, Postgrad Med J 2006:82: 468-70 ) 44% had diagnosis made after discharge birth clinic

9. Factors frustrating diagnosis and treatment of Pediatric Heart Disease in developing countries

10. at risk intrauterine growth retardation low birth weight SA: 12 -22% prematurity discharge < 2days of age chromosomal abnormalities multiple malformations specific lesions CoA Truncus Ebstein HLHS ASD

11. problems: early detection in SA early discharge after delivery IMR: SA - 59,44 / 1000 India – 34.61 access to clinics lack of effective referral pathway distances transport system human resources nursing medical HIV economic awareness medical patients poverty lack of research - epidemiology

12. Screening methods Clinical examination Saturation monitoring Echocardiographic screening

13. Clinical screening varied reports examination at birth – 50% detection UK study – adequate training 70 – 80% small team examining predischarge + structured referral pathway – 90% detection does not matter whether physician or registered nurse experienced team structured referral structured referral CME Arch Dis Child Fetal Neonatal 2006;91:F263-7

14. Saturation monitoring R hand & R foot SO2 < 95% cut-off sensitivity : 63% specificity: 99.8% false positive rate: 0.2% Arch Dis Child Fetal Neonatal 2007;92:F176-80 Pediatr Cardiol. 2007 Oct 12 ePub 7962 children 38 -62% not reliable – not universal screening human factors have an impact adequate training & time

15. Echocardiographic Screening Echocardiography improves detection expensive – reduce cost of OPD referrals J Perintal Med 2002;30;307-12 Antenatal 20weeks detection rate average: 23% range: 3 – 68% advantage early detection delivery in high risk unit

16. Top 10 actions for enhanced Pediatric Health in Developing Countries 1. more local and international poverty reduction initiatives 2. school based heart health education 3. primary prevention (RF) 4. school based Rx programmes for RF 5. develop specialized staff in pediatric heart disease 6. research – etiology & predisposition to CHD 7. improve early antenatal and perinatal screening 8. more screening of fetal hearts by ultrasound 9. family planning & genetic counseling 10. improved local and academic centres for pediatric CVS medicine+surgery

17. Suggestions: improved heart health in SA effective referral pathway easier & faster outreach clinics awareness programmes Provincial boundaries training + support SO 2 monitors Echocardiography antenatal screening telemedicine DOH resources pediatric cardiologists + surgeons research

18. “we have an obligation as uniquely talented individuals to change the boundaries of our thinking, the boundaries of our influence and the boundaries of our efforts”