Recognition & referral in the periphery

SC Brown

Division Pediatric Cardiology

Department of Pediatrics & Child Health

University of the Free State

Bloemfontein

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

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

Epidemiology: Rheumatic fever

prevalencedeveloping countries: 1.2/1000 4.5 /1000 AfricaSA ??

implicationsRheumatic heart disease = continuing burden

Incidence ARF & prevalence RHD in Aboriginal Australians – Dpt of Health and community services,

Northern AutraliaP

revale

nce R

HD

per 1

00

0

Incid

en

ce o

f A

RF p

er

10

00

< 5 5-14 15-24 25-34 > 34

15

35

200

400

RHD

2003

ARF

2002

Burden of Pediatric Heart Disease: South Africa: prevalence 2004

SA population: 42,7 mil % children < 16: 6 834 965 RHD 7 518 CHD 8 885 both 16 403

Children’s Heartlink Review of WHO data

HIV – exposed & infected ??

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)

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

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

20%

30%

5%

10%

23%

12%

economic

lack of knowledge

distance

lack of training

lack cardiologists

other

at riskintrauterine growth retardationlow birth weight SA: 12 -22%

prematuritydischarge < 2days of agechromosomal abnormalitiesmultiple malformationsspecific lesions

CoA Truncus Ebstein HLHS ASD

problems: early detection in SA

early discharge after delivery IMR:

SA - 59,44 / 1000 India – 34.61

access to clinicslack of effective referral pathwaydistancestransport systemhuman resources

nursing medical

HIVeconomicawareness

medical patients

poverty

lack of research - epidemiology

Screening methods

Clinical examination

Saturation monitoring

Echocardiographic screening

Clinical screening

varied reportsexamination 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 referralstructured referral CME

Arch Dis Child Fetal Neonatal 2006;91:F263-7

Saturation monitoringR hand & R foot

SO2 < 95% cut-offsensitivity : 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

Echocardiographic ScreeningEchocardiography 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

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

Suggestions: improved heart health in SA

effective referral pathway easier & faster outreach clinics awareness programmes Provincial boundaries

training + support

SO2 monitorsEchocardiography antenatal screening telemedicine

DOH resources pediatric cardiologists + surgeons

research

12%

23%

10%

5%

30%

20%

“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”