Cyanosis in Infants

Aka: Cyanosis in Infants, Neonatal Cyanosis

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II. Precautions

  1. Cyanosis is related to the absolute Hemoglobin concentration (not the oxygenated-deoxygenated ratio)
  2. Conditions in which Cyanosis manifests at higher Oxygen Saturations (early sign)
    1. Increased Hemoglobin (e.g. Polycythemia Vera, most newborns)
  3. Conditions in which Cyanosis manifests at lower Oxygen Saturations (delayed sign)
    1. Anemia
    2. Increased fetal Hemoglobin ratio to adult Hemoglobin

III. Causes: Transient Cyanosis after Delivery

  1. Central Cyanosis
    1. Central Cyanosis is a concerning sign outside the first few minutes of life
    2. Central Cyanosis should clear in minutes of birth
    3. Tongue and Mucus membranes are pink initially in normal newborns
  2. Acrocyanosis (Peripheral Cyanosis)
    1. Bluish-gray distal extremities
    2. Results from slow flow in the peripheral capillary beds
    3. Does not correlate with PaO2
    4. Clears within 1-2 days

IV. Causes: Cyanotic Cardiac Defect

  1. See Congenital Heart Disease
  2. Transposition of the Great Vessels
  3. Total Anomalous Pulmonary Venous Return
  4. Ebstein's Anomaly
  5. Tricuspid Atresia
  6. Pulmonary Atresia with Intact Ventricular Septum
  7. Severe Pulmonary Stenosis
  8. Severe Tetralogy of Fallot
  9. Associated Congestive Heart Failure Causes
    1. Hypoplastic Left Heart Syndrome
    2. Truncus Arteriosus

V. Causes: Lung Disorders

  1. Transient Tachypnea of the Newborn
  2. Respiratory Distress Syndrome
  3. Aspiration
    1. Meconium Aspiration
    2. Blood or amniotic fluid aspiration
  4. Pneumonia
  5. Pneumothorax
  6. Pleural Effusion
  7. Congenital Diaphragmatic Hernia
  8. Persistent Pulmonary Hypertension

VI. Causes: Airway Disorders

  1. Choanal Atresia
  2. Pierre-Robin Syndrome
  3. Macroglossia
  4. Vascular Ring or Pulmonary Sling
  5. Neck Mass (e.g. Cystic Hygroma)

VII. Causes: Miscellaneous

  1. Apnea or asphyxia
  2. Hemorrhage
  3. Seizure
  4. Hypothermia
  5. Electrolyte abnormality
    1. Hypoglycemia
    2. Hypocalcemia
    3. Hypermagnesemia

VIII. Causes: Cyanosis with normal pO2

  1. Methemoglobinemia (decreased and refractory Oxygen Saturation)
  2. Polycythemia
  3. Vasoconstriction (e.g. Cold environment)

IX. Diagnostics

  1. Chest XRay
  2. Electrocardiogram
  3. Hematocrit
  4. Arterial Blood Gas on 100% oxygen
    1. Arterial pO2>200 rules out Congenital Heart Disease
  5. Simultaneous Pre-Ductal, Post-Ductal Arterial Blood Gas
    1. Indications
      1. No obvious pulmonary cause
      2. Persistent pO2 <100 mmHg
    2. Interpretation: No difference in pre and post pO2
      1. Suggests right to left shunt via ductus arteriosus
      2. Causes
        1. Persistent Pulmonary Hypertension
        2. Critical Aortic Coarctation
        3. Interrupted Aortic Arch

X. Management

  1. Follow initial protocol per Neonatal Resuscitation
  2. Congenital Heart Disease Management
    1. Consider Prostaglandin E1
    2. Manage associated CHF

XI. References

  1. Joseph and Webb (2015) Crit Dec Emerg Med 29(1): 10-8
  2. Cloherty (1991) Neonatal Care, Little Brown, p. 261-70
  3. Fuloria (2002) Am Fam Physician 65(1):61-8 [PubMed]

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