Birth prevalence of CHD is similar worldwide, currently estimated at 10 to 12 per 1,000 live births.14 Early detection is important not only to provide optimal therapy, but also prevent further complications. CHD can be categorized into two groups, cyanotic and non-cyanotic CHD. Cyanotic CHD can be easily detected since birth and childhood, while non-cyanotic CHD can be asymptomatic or with minimal symptoms which can be undetected until complications manifest.
In developed countries, such as Japan, many methods of heart disease screening have been established which are conducted during various stages of children’s growth.5,6,15 Screening of CHD does not need sophisticated tools, since by utilizing simple equipment it is still possible to find suspected CHD patients. One of the most effective methods is by using fetal ECG, which is able to visualize the fetal heart during pregnancy, thus early detection of a congenital heart anomaly can be done.16 In Indonesia, it is mandatory for pregnant women to have at least three ultrasonography (USG) examinations during antenatal care. Once during early pregnancy, to determine gestational age, fetal viability, number and positions of the fetus, as well as detection of any major fetal abnormality. Then, next is at 20 weeks of pregnancy, to detect fetal abnormality, followed by USG examination during the third trimester to prepare for labor. Sadly, in Indonesia many pregnant women do not go through all examinations due to various reasons, such as financial problem, no experienced health provider in the area, and customary beliefs. Thus, many fetuses with a congenital anomaly are left undiagnosed until birth or later as adults.
In the United States, toolkits or guidelines on CHD screening have been published. The Children’s National Medical Center published a screening toolkit on critical CHD. This guideline recommends the use of pulse oximetry in newborns to identify critical CHD, a more serious form of CHD that requires intervention in the first year of life. It is also mentioned in the guidelines that detection of heart defect during postnatal period, which is currently done based on symptoms and physical examination within the first 24 hours of life, was proven to effectively have found only 50% of infants with heart defects. Nevertheless, pulse oximetry could help identify newborns or infants with low levels of oxygen and help make faster diagnosing of critical CHD.5
Other methods have also been developed such as heart auscultation examination with stethoscope, 12 lead electrocardiogram, peripheral saturation examination using pulse oximetry while resting and after activities, heart exercise examination, and ECG. In Japan, these examinations are being done at many stages of child growth, from fetus until secondary school. The screening system has been conducted in Japan from 1995 and has been proven to significantly reduce sudden death within school settings. Thus, these methods should be considered in Indonesia.6
In Indonesia, child health has been one of the top priorities of the Ministry of Health. Programs have been done in maintaining infant and child health that must be addressed to prepare healthy, intelligent, and good quality future generations and to reduce infant and child mortality. The programs are conducted since the fetus was still in the womb, at birth, after birth, and until the age of 18 (eighteen) years. Programs in school-age levels are school health programs for elementary school and adolescences healthcare. According to the Ministry of Health, school-age children are strategic targets for health program implementations, because they are large in numbers and also accessible because they are well organized. Programs for older children or adolescences focus more on improving skills and knowledge in health education, such as appointment of Young Doctors (Dokter Kecil) and Adolescences Healthcare. For younger children, mainly first year elementary students, health screening or medical examination is done every year, usually at the beginning of the new school term. However, the current screening does not involve examination on cardiac health.
This study aimed to find possibilities to implement and incorporate heart screening for children in Indonesia with the current health screening and find prevalence of congenital heart disease by using ECG. Teams from primary health cares performed examinations of primary screening, and each team consisted of health personnel, which were general practice doctor(s) and nurse(s). The primary screening was performed concomitant with yearly medical examinations for first grade elementary school. Negative evaluations on the implementation of the primary screening are mainly due to lack of resources, either human resources or logistics. Nevertheless, the primary CHD screening was feasible and considerably easy to perform and was able to diagnose children with suspected heart abnormalities.
There are possibilities of bias and subjectivity that can affect the outcomes of this study. Previous study on primary physicians or general practioners’ skills on pediatric cardiac auscultation showed low performances independent of training levels.17 Therefore, possibilities of under or over diagnoses of heart murmurs could have happened during primary screening. Additional trainings on heart auscultation prior to primary screening for primary health care doctors who would perform the heart murmur examinations are needed to improve their performance.