Urgent considerations

See Differentials for more details

In most healthy infants, the oxygen saturation rises to >90% by 10 minutes of age.[5] All cases of newborn cyanosis persisting beyond the first 10 minutes postpartum require immediate attention. Most cases of persistent newborn cyanosis are due to cardiopulmonary causes that require rapid intervention with a goal of maintaining oxygen saturation >90%.

  • Oxygen administration should occur prior to evaluation of the underlying cause.

  • Oxygen saturation should be maintained >90%, except in the presence of cyanotic cardiac lesions (which increase risk for pulmonary overcirculation, and where a target range of 75% to 85% is typically recommended).[6][7][8]​​​​​

  • Assisted ventilation should be considered for all infants with severe cyanosis.[9] Effective positive-pressure ventilation should be prioritized in newborns requiring support​.[10] For preterm newborn infants, use nasal continuous positive airway pressure (CPAP) if possible, rather than invasive ventilation.[9] There is insufficient evidence to suggest for or against the use of exhaled carbon dioxide to guide noninvasive intermittent positive-pressure ventilation (with face masks, supraglottic airways, or nasal cannulas) in infants immediately after birth.[11]​​​

Preterm neonates may require surfactant administration through a tracheal tube to increase lung compliance.[9] Surfactant administration is essential to treat respiratory distress syndrome.[12]​​

Vascular access should be established for infusion of drugs and/or fluids:

  • Fluids and vasopressors (dopamine, dobutamine, or epinephrine) should be given for hypotension and shock.

  • Antibiotics should be given if there is evidence of sepsis (see below) or pneumonia.

  • Alprostadil (prostaglandin E1) infusion should be given to maintain patency of ductus arteriosus in suspected ductal-dependent congenital cardiac conditions.

Administration of alprostadil as an intravenous infusion is life-saving in infants with ductal-dependent cyanotic cardiac lesions. Treatment should therefore be initiated without delay if this cause is suspected, keeping in mind that apnea can result from alprostadil administration.

Symptomatic hypoglycemia and hypocalcemia should be corrected with intravenous administration of glucose or calcium, as these conditions can give rise to apnea (with or without seizures).

Cyanotic infants with suspected congenital heart disease should be transferred to a tertiary care center immediately for further management and treatment with balloon septostomy and/or surgery as necessary. Infants with severe pulmonary hypertension should be referred to a center equipped with nitric oxide.

Sepsis

Cyanosis may be a presenting symptom of sepsis. Sepsis is a spectrum of disease, where there is a systemic and dysregulated host response to an infection.[13]​ Presentation ranges from subtle, nonspecific symptoms (e.g., feeling unwell with a normal temperature) to severe symptoms with evidence of multiorgan dysfunction and septic shock. Patients may have signs of tachycardia, tachypnea, hypotension, fever or hypothermia, poor capillary refill, mottled or ashen skin, cyanosis, newly altered mental state or reduced urine output.[14] Sepsis and septic shock are medical emergencies.

Risk factors for sepsis include: age under 1 year, impaired immunity, recent surgery or other invasive procedures, any breach of skin integrity, and indwelling lines or catheters.[14]

Early recognition of sepsis is essential because early treatment improves outcomes.[14][15][Evidence C]​ ​However, detection can be challenging because the clinical presentation of sepsis can be subtle and nonspecific. A low threshold for suspecting sepsis is therefore important. The key to early recognition is the systematic identification of any patient who has signs or symptoms suggestive of infection and is at risk of deterioration due to organ dysfunction. Criteria to identify sepsis and septic shock in children and young people under the age of 18 years have been developed.[16]​ Several other risk stratification approaches exist. All rely on a structured clinical assessment and recording of the patient's vital signs.[14][16]​​[17][18]​​​​​​​​​​[19]​​​​ It is important to check local guidance for information on which approach your institution recommends. The timeline of ensuing investigations and treatment should be guided by this early assessment.[19]

Treatment guidelines have been produced by the Surviving Sepsis Campaign and remain the most widely accepted standards.[15]​ Within the first hour:[15]

  • Follow institutional protocols for management of sepsis/septic shock in neonates; these improve the speed and reliability of care

  • Obtain blood cultures before administering antibiotics (provided this does not substantially delay antibiotic administration)

  • Administer broad-spectrum antibiotics

  • Administer crystalloid fluids, titrated to clinical signs of cardiac output and stopped if there is evidence of volume overload. Consult local protocols.

Use trends in blood lactate levels to guide resuscitation. If the child's hypotension is refractory to fluid resuscitation, consider use of vasopressors.[15]

For more information on sepsis, see Sepsis in adults and Sepsis in children.

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