Heart

o   Purpose= early identification of congenital heart problems.

o   Congenital heart disease (CHD) is a term used to describe a problem with the heart’s structure and function that is present at birth.

o   Overall incidence of CHD = 8 per 1,000

o   Critical congenital heart disease (CCHD) accounts for 15% to 25% of these and is a leading cause of morbidity and mortality.

Congenital heart abnormalities can be categorised as:

·         CCHD (all potentially life-threatening duct-dependent conditions and those conditions that require procedures within the first 28 days of life)

·         Major serious CHD (defects not classified as critical but requiring invasive intervention in the first year of life)

·         Some critical and major cardiac lesions may be detected during pregnancy as part of the NHS fetal anomaly screening programme (FASP), during the 20-week ultrasound scan. The acceptable FASP standard target detection rate for specific cardiac abnormality is at least 50%.

Risk factors include:

• Family history of CHD (1st degree)
• Fetal trisomy or other trisomy diagnosed
• Cardiac anormality suspected from antenatal scan
• Maternal exposure to viruses, e.g. rubella, during early pregnancy
• Maternal conditions such as diabetes, epilepsy
• Teratogenic drugs taken during pregnancy

Before examination, should establish information regarding:

• Mother's medical and recent obstetric history, including any medication
• Baby's family history
• Baby's immediate postnatal health

Parents should be asked if their baby:

• Ever gets breathless or changes colour at rest or while feeding
• Is not feeding well or too tired to feed, quiet, lethargic, or poor muscle tone

Observation:

• General tone
• Central and peripheral colour
• Size and shape of chest
• RR
• Symmetry of chest movement, use of diaphragm and abdominal muscles
• Signs of respiratory distress (recession/grunting)

Palpation

• Femoral and brachial pulses for strength, rhythm and volume
• Assessment of perfusion through capillary fill time
• Position of cardiac apex (to exclude dextrocardia)
• Palpation of liver to exclude hepatomegaly
• Vibratory sensation felt on the skin (+/- thrill) 

Auscultation includes identification of a murmur, either systolic or diastolic or loudness. It also includes the assessment of the quality of heart sounds at:

·         second intercostal spaces adjacent to the sternum left (pulmonary area)

·         second intercostal spaces adjacent to the sternum right (aortic area)

·         lower left sternal border in the fourth intercostal space (tricuspid area)

·         apex (mitral area)

·         midscapulae (coarctation area)

• Senior paediatrician with expertise in cardiology review in the early neonatal period as required- urgency will depend on suspected condition.
• If a suspected major or critical heart condition is found on the NIPE newborn screening examination, the baby should be seen as a matter of urgency and definitely before discharge home.
• Follow the locally agreed referral process. Urgency will depend on the clinical condition of the baby.

Signs and symptoms that suggest a major congenital heart abnormality

·         Tachypnoea at rest

·         Episodes of apnoea lasting longer than 20 seconds or associated with colour change

·         Intercostal, sub-costal, sternal or supra-sternal recession, nasal flaring

·         Central cyanosis

·         Visible pulsations over the precordium, heaves, thrills

·         Absent or weak femoral pulses

·         Presence of cardiac murmurs or extra heart sounds

Sigificant Murmors are:

·         usually loud

·         usually heard over a wide area

·         usually with a harsh rather than soft quality

·         possibly associated with other abnormal findings

Benign murmurs are usually:

• Short, soft, systolic and localised to the left sternal border
• No added sounds or other clinical abnormalities associated with them

Practitioner should discuss findings with a senior paediatrician or a paediatrician with expertise in cardiology and refer as appropriate.

Urgency will depend on assessment of clinical condition of baby

Many babies will have murmurs in first 24 hours of life in the absence of a cardiac defect (linked to physiological changes at birth), however, murmurs may be absent in babies with a significant cardiac defect

Heart screening standards:

Although there are no NIPE heart screening standards, it is recommended that the national clinical pathway above is followed. Practitioners should be familiar with, understand and follow any existing local policies, guidelines and referral pathways.

Screen Negative

• Have NIPE in 6-8wks 
• Follow Healthy Child Programme
• Parents should be advised to contact their healthcare professional/emergency services if they have concerns about their baby