Overview of cyanosis in the newborn
- Eric C Eichenwald, MD
Eric C Eichenwald, MD
- Professor of Pediatrics
- Perelman School of Medicine, University of Pennsylvania
Cyanosis is a bluish discoloration of the tissues that results when the absolute level of reduced hemoglobin in the capillary bed exceeds 3 g/dL [1-3]. The appearance of cyanosis depends upon the total amount of reduced hemoglobin rather than the ratio of reduced to oxygenated hemoglobin. Cyanosis is a common clinical finding in newborn infants. Neonatal cyanosis, particularly central cyanosis, can be associated with significant and potentially life-threatening diseases due to cardiac, metabolic, neurologic, infectious, and parenchymal and non-parenchymal pulmonary disorders (table 1).
The etiology, evaluation, and initial management of the newborn with cyanosis will be reviewed here.
CENTRAL VERSUS PERIPHERAL CYANOSIS
Peripheral cyanosis — Patients with peripheral cyanosis have normal systemic arterial oxygen saturation and increased tissue oxygen extraction that leads to a widened systemic arteriovenous oxygen difference of 60 percent (from the normal 40 percent) resulting in an increased concentration of reduced hemoglobin on the venous side of the capillary bed. Peripheral cyanosis typically affects the distal extremities and sometimes the circumoral or periorbital areas . The extremities may be cool or clammy. Peripheral cyanosis may be associated with peripheral vasoconstriction or many causes associated with central cyanosis. In neonates with peripheral cyanosis, the mucus membranes remain pink, which differentiates it from central cyanosis
Acrocyanosis — Acrocyanosis is often seen in healthy newborns and refers to the peripheral cyanosis around the mouth and the extremities (hands and feet) (picture 1). It is caused by benign vasomotor changes that result in peripheral vasoconstriction and increased tissue oxygen extraction and is a benign condition . Acrocyanosis is differentiated from other causes of peripheral cyanosis with significant pathology (eg, septic shock) as it occurs immediately after birth in healthy infants. It is a common finding and may persist for 24 to 48 hours.
Central cyanosis — Central cyanosis is caused by reduced arterial oxygen saturation. Newborn infants normally have central cyanosis until up to 5 to 10 minutes after birth, as the oxygen saturation rises to 85 to 95 percent by 10 minutes of age . Persistent central cyanosis is always abnormal and should be evaluated and treated promptly.
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- CENTRAL VERSUS PERIPHERAL CYANOSIS
- Peripheral cyanosis
- - Acrocyanosis
- Central cyanosis
- - Pathogenesis
- FACTORS THAT AFFECT CYANOSIS DETECTION
- Hemoglobin concentration
- Fetal hemoglobin
- Skin pigmentation
- Other physiologic factors
- CAUSES OF PERIPHERAL CYANOSIS
- CAUSES OF CENTRAL CYANOSIS
- Hypoventilatory disorders
- - Airway abnormalities
- - Neurologic disorders
- - Metabolic disorders
- Pulmonary disorders
- - Ventilation-perfusion mismatch
- - Impaired alveolar-arterial diffusion
- Disorders with right to left shunting
- - Cyanotic congenital heart disease
- - Persistent pulmonary hypertension of the newborn
- Hematologic causes
- - Hemoglobinopathies
- - Polycythemia
- Pulse oximetry measurement
- Physical examination
- Initial tests
- - Arterial blood gas
- - Other blood tests
- - Chest radiograph
- Further testing
- - Hyperoxia test
- - Echocardiography
- INITIAL MANAGEMENT
- SUMMARY AND RECOMMENDATIONS