Congenital Heart Disease In Children: Pitfalls To Avoid

1. “If the patient had CHD, the diagnosis would have been made in utero or prior to leaving the newborn nursery.” Recent studies estimate that greater than 60% of CHD cases are not diagnosed on antenatal ultrasound. Most neonates with CHD are clinically asymptomatic immediately after birth. Even when abnormalities such as a murmur are detected on physical examination, many will not be directly referred to a pediatric cardiologist.

2. “The patient is greater than 1 week old, so the diagnosis cannot be a ductal-dependent CHD. The DA should have closed days ago.” Patients with ductal-dependent cardiac disease, especially ductal-dependent systemic blood flow, may have persistence of DA patency beyond 24 hours of life as a result of increased DA blood flow. Cardiovascular collapse in a child less than 1 month of age should be considered as a CHD with ductal-dependent systemic blood flow until proven otherwise.

3. “The infant is febrile. We should evaluate and treat for sepsis. CHD is not likely.” While sepsis is more common and should be suspected in any neonate presenting to the emergency department with tachypnea, cyanosis, or shock, a diagnosis of CHD should not be excluded based solely on the presence of fever. In fact, the presentation of a patient with CHD may be precipitated by an infectious process.

4. “The blood pressure and SpO2 obtained in triage are normal. I’m reassured.” Infants presenting to the emergency room in distress should have blood pressure and SpO2 measurements performed on the right upper extremity and one lower extremity. A discrepancy between the two extremities is suggestive of CHD.