Cyanotic Newborn

By far the most common causes of cyanosis in the newborn are respiratory (pneumonia, newborn respiratory distress syndrome [NRDS], meconium aspiration, etc.). Babies with respiratory illness are frequently in respiratory distress (grunting, flaring, retracting, tachypneic), whereas patients with cardiac causes are not (the “happy blue baby”). This page focuses on cardiac causes.

Differential Diagnosis

• Transposition of the great vessels (TGV)
  –The most common cardiac cause of cyanosis in the newborn
  –Aorta connected to RV and pulmonary artery connected to LV
  –PE, ECG normal
  –CXR: Normal or egg-on-string

• Tetralogy of Fallot
  –Most common cyanotic heart disease
  –Right ventricular hypertrophy, pulmonary stenosis, VSD, and an overriding aorta
  –Associated with 22q11 deletion
  –Murmur; reduced PVM; R-axis deviation, RVH

• Critical pulmonary valve stenosis
  –Thickened pulmonary valve
  –Murmur; reduced PVM; RVH

• Pulmonary atresia
  –No flow from RV to pulmonary artery, so pulmonary blood flow depends on ductus arteriosus
  –PE normal; reduced PVM; reduced R-sided forces with normal axis

• Tricuspid atresia
  –No inflow into R ventricle, causing R ventricular hypoplasia
  –With or without murmur; reduced PVM; reduced R-sided forces with L-axis deviation

• Truncus arteriosus
  –Single outlet to ventricles divides into aorta and pulmonary arteries
  –VSD always present
  –PE normal; possibly increased PVM; ECG normal

• Total anomalous pulmonary venous return
  –Cardiac cause of cyanosis that mimics respiratory disease with respiratory distress and “white-out” of lungs
  –Consider for patients who appear to have bad respiratory disease
  –With or without murmur; increased PVM; ECG normal

• Ebstein anomaly
  –The tricuspid valve is displaced down into the R ventricle, usually with severe tricuspid regurgitation with R-to-L atrial level shunting
  –Murmur; huge heart; R atrial enlargement (tall P waves)

• Other: Respiratory most common, polycythemia, hypoglycemia

Workup and Diagnosis

• History
  –Sometimes a family history of congenital heart disease
  –Usually presents on second day of life rather than in the delivery room

• Physical exam
  –Almost all patients with cyanotic heart disease have single S₂, however, splitting of S₂ difficult to appreciate in babies due to fast heart rate
  –See Differential Diagnosis for findings by lesion

• Hyperoxia test
  –Used to differentiate cardiac from respiratory causes
  –Administration of 100% O₂ for 10 minutes
  –PaO₂ improves with respiratory causes of cyanosis, but not cardiac causes, because oxygenated blood in the lungs is not transported systemically
  –Arterial blood gas PaO₂ >200 is more indicative of respiratory disease; <100 consistent with cyanotic heart disease or very severe respiratory disease

• Chest X-ray shows PVM, cardiac silhouette

• Electrocardiogram
  –Evaluates the presence/absence of R ventricle
  –Normal newborns have a dominant R wave in lead V1 with a QRS axis of 60–180

Treatment

• NICU admission with cardiac monitor, pulse oximetry
  
• Supplemental O₂ rarely helps with cardiac cyanosis, because the blood does not get to the lungs
• Prostaglandin E1 used to open the ductus arteriosus and increase blood flow to the lungs
  –Side effects: Apnea (more common at higher doses)
  –Must be prepared to intubate (advisable before transport to a referral center)
  –Fever and hypotension (via vasodilation)

• Blalock-Taussig shunt
  –Gore-Tex tube graft surgically placed from the innominate artery to the pulmonary artery
  –Improves pulmonary blood flow
• Balloon atrial septostomy
  –In TGV, improves cyanosis by atrial mixing
  –Catheter placed into L atrium, balloon inflated, and pulled back to R atrium to enlarge the atrial foramen
• Anatomy determines further surgical repair or palliation

Book Source Details

• Book Title: In A Page: Pediatric Signs and Symptoms
• Author(s): Jonathan E. Teitelbaum, Kathleen O. Deantonis, Scott Kahan
• Year of Publication: 2007
• Copyright Details: In A Page: Pediatric Signs and Symptoms, Copyright © 2007 Lippincott Williams & Wilkins.

Other Book Chapters Related to Cyanosis

Read excerpts from these other book chapters related to Cyanosis:

Copyright Details: In A Page: Pediatric Signs and Symptoms, Copyright © 2008 Williams & Wilkins.

More About Causes of Cyanosis

• Back to symptom: Cyanosis: Introduction (review 448 causes)
• Next Book Extract About Cyanosis: CYANOSIS (Differential Diagnosis in Primary Care)
• All Book Extracts: All Online Book Extracts for Cyanosis

More About This Book: Title: In A Page: Pediatric Signs and Symptoms Authors: Jonathan E. Teitelbaum, Kathleen O. Deantonis, Scott Kahan Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 1-4051-0427-9

 » Next page: CYANOSIS (Differential Diagnosis in Primary Care)

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