Congenital heart disease (CHD) is common and important as it remains a leading cause of neonatal morbidity and appreciable mortality. Prenatal diagnosis, the presence of a murmur, cyanosis, tachypnoea and/or poor or differential peripheral pulses raise the suspicion of CHD aided by differential pre/postductal saturations. Yet even serious CHD may not be considered when such clues are absent. Nevertheless, there are clinical cues which may alert the clinician to the possibility of a significant CHD which may lead to an early and accurate diagnosis and appropriate intervention to achieve best results. This paper addresses these issues which become especially difficult if caring for infants away from facilities provided by tertiary centres. Tachypnoea on the first postnatal day is generally non-cardiac in origin. Exceptions include large arteriovenous fistulae and/or ‘pump’ (ventricular) failure. In addition, attention is drawn to two important confounding factors in the newborn, namely the patency of the ductus arteriosus and the initially high pulmonary vascular resistance, both of which alter and may mask the clinical findings of a serious cardiac abnormality. An appreciation of the physiological changes that occur in early infancy will aid the clinician’s understanding of CHD as it affects the newborn.
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