HeartCalc / CCHD screen

CCHD Pulse-Ox Screen Experimental

Newborn critical congenital heart disease screening: updated AAP algorithm (Martin 2020; AAP 2025)

Does the screen apply?

Signs of CCHD, or a prenatal or known diagnosis of CHDCyanosis, poor perfusion, respiratory distress, murmur needing evaluation. These infants need evaluation, not a screen. Receiving supplemental oxygenThe screen is done in room air.

Age at first screen hours

The algorithm screens at 24 hours of age or later, or as late as possible if the infant is discharged earlier. The thresholds were not designed for high altitude; follow your state program there.

Screen 1

Right hand SpO₂ % Foot SpO₂ %

Whole numbers as the oximeter shows them, at a stable reading. Either foot.

Screen 2 (repeat, 1 hour later)

Only needed when screen 1 is neither pass nor fail.

Right hand SpO₂ % Foot SpO₂ %

Model, equations and sources

Algorithm

Screen 1 (age ≥24 h, room air; right hand = pre-ductal, foot = post-ductal)
  Any SpO2 <90% (hand or foot)                          -> FAIL
  Hand ≥95% AND foot ≥95% AND |hand - foot| ≤3%       -> PASS
  Otherwise (90-94% in hand or foot, OR difference >3%) -> REPEAT once in 1 hour

Screen 2
  Any SpO2 <90%                                         -> FAIL
  Hand ≥95% AND foot ≥95% AND |hand - foot| ≤3%       -> PASS
  Otherwise                                             -> FAIL (no third screen)

Martin 2020 (expert panel) recommended two changes to the 2011 AAP algorithm: “requiring an oxygen saturation of at least 95% in both (formerly either) the upper and lower extremities to pass” and “requiring only 1 repeat screen instead of 2 for cases that neither pass nor fail initially” (abstract). The 2025 AAP clinical report (Oster 2025) endorsed this as the new AAP algorithm.
The branch wording above follows the CDC summary of the AAP algorithm (fail: any measure <90% in either the right hand or foot on the initial or repeat screen; <95% in either on 2 measures; >3% difference on 2 measures, each separated by 1 hour; pass: ≥95% in both and ≤3% absolute difference) and the Tennessee Department of Health protocol that cites Martin 2020. The AAP figure itself was not retrieved for this prototype.
The difference is absolute: a foot reading higher than the hand counts the same as a lower one (as in the CDC wording, “≤3% absolute difference”).
Published example (Tennessee protocol): “a 96% in the foot and 100% in the hand after one repeat would fail”. This page gives the same answer.
One edge case: a first screen that is borderline only because of a >3% difference, followed by a repeat with both values 90–94% and no difference, meets neither CDC “2 measures” rule literally. Because the updated algorithm allows only one repeat, this page calls any repeat that does not pass a fail, as the Tennessee flowchart does.

After the screen (Tennessee protocol, citing Martin 2020)

Fail: notify the medical practitioner; evaluate for other causes of low saturation (for example persistent pulmonary hypertension, pneumonia, infection); in the absence of a clear cause, obtain a diagnostic echocardiogram interpreted by an expert in infant echocardiography, reviewed before discharge. SpO₂ <90% at any time needs immediate clinical assessment and no rescreen.
Pass: does not exclude a cardiac disorder. If cardiac evaluation is otherwise indicated (clinical signs, prenatal diagnosis, dysmorphic features), proceed even after a pass.
State programs differ in details (for example, the Tennessee protocol adds a foot-first step and rules for screens before 24 hours). Follow your state's protocol.

Input checks

SpO₂ must be a whole number from 50 to 100%. Age 0–720 hours; under 24 hours gives a caution, not a block.

References

Martin GR, Ewer AK, Gaviglio A, et al. Updated strategies for pulse oximetry screening for critical congenital heart disease. Pediatrics 2020;146(1):e20191650. doi:10.1542/peds.2019-1650 (abstract read via PubMed; full text not retrieved).
Oster ME, Pinto NM, Pramanik AK, et al. Newborn screening for critical congenital heart disease: a new algorithm and other updated recommendations: clinical report. Pediatrics 2025;155(1):e2024069667. doi:10.1542/peds.2024-069667 (abstract).
Centers for Disease Control and Prevention. Clinical screening and diagnosis for critical congenital heart defects: cdc.gov/heart-defects/hcp/screening (read October 2026).
Tennessee Department of Health. Protocol for Critical Congenital Heart Disease (CCHD) Screening, revised 9/21/2021: tn.gov (PDF).

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A pass can falsely reassure: pulse-oximetry screening does not detect every critical heart defect. Clinical examination still matters.