**3. Evaluation**

During a physical examination if an infant appears blue, the following questions need immediate answer:

### **3.1 Does the infant have respiratory distress?**

If the infant has increased respiratory effort with increased rate, retractions and nasal flaring, respiratory disease should be high on the list of differential diagnosis. Cyanotic heart disease usually presents without respiratory symptoms but can have effotless tachypnea ( rapid respiratory rate without retractions).

### **3.2 Does the infant have murmor?**

A murmor usually implies heart disease. Transposition of great vessels can present without a murmor.

#### **3.3 Is the cyanosis continous, intermittent, sudden in oncet or occuring only with feeding?**

Intermittent cyanosis is more common with neurologic disorders, as these infants may have apneic spells alternating with periods of normal breathing. Continuous cyanosis is usually associated with intrinsic lung disease or heart disease. Cyanosis with feeding may occur

Evaluation and Emergency Treatment of

**4. Cardiac disease** 

the newborn (PPHN).

**5.1 Physical examination** 

**3.5 What is the prenatal and delivery history?** 

**5. Cardiac evaluation of newborn infant** 

films of the neonate are briefly reviewed in this chapter.

1. Normal physical findings that are unique in normal newborn infants

shunt through the patent foramen ovale (PFO).

from 70 to 180 beats/min) than that of older children and adults. b. A varying degree of acrocyanosis is the rule rather than the exception.

a. Heart rate is generally faster ( usually over 100 beats/min, with normal ranges

c. Mild arterial desaturation with arterial Po2 as low as 60 mmHg is not unusual in an otherwise normal neonate. This may be caused by an intrapulmonary shunt through an as yet unexpanded portion of the lungs or by a right-to-left arterial

Cesarean section is associated with increased respiratory distress.

Criticlly Ill Neonate with Cyanosis and Respiratory Distress 235

An infant of a diabetic mother has increased risk of hypoglycemia, polycytemia, respiratory distress syndrome and heart disease. Infection, which can occur with premature rupture of membranes, may cause shock and hypotension with resultant cyanosis. Amniotic fluiod abnormalities, such as oligohydramnios ( associated with hypoplastic lungs ) or polyhydramnios ( associated with esophageal atresia ), may suggest a cause for cyanosis.

Congenital heart disease produces cyanosis when obstruction to right ventricular outflow causes intracardiac right-to-left shunting or when complex anatomic defects, unassociated with pulmonary stenosis, cause an admixture of pulmonary and systemic venous return in the heart. Cynosis from pulmonary edema may also develop in patients with heart failure caused by left-to-right shunts, although the degree is usually less severe. Cyanosis may be caused by persistence of fetal pathways, for example, right-to-left shunting across the foramen ovale and ductus arterious in the presence of persistent pulmonary hypertension of

In the cardiac evaluation of the newborn infant, understanding the circulatory status at birth is very important. As the result of fetal circulation, newborn infants have right ventricular (RV) dominance associated with a thick RV wall, elevated pulmonary vascular resistance (PVR), and a thick medial layer of the pulmonary arterioles. The thick pulmonary artery smooth muscle gradually becomes thinner, and it resembles that of the adult by the time the baby is age 6 to 8 weeks. Most perinatal changes in hemodynamics are related to the thinning of the pulmonary vascular smooth muscle, resulting in a gradual fall in the PVR and a loss of RV dominance of the neonate. Premature infants in general have lessRV dominance than full-term infants, and the PVR is not as high in the full-term neonate, which adds variability to the process. Because of these unique aspects of the perinatal circulatory system, the basic tools in the initial cardiac evaluation discussed are less reliable and the findings may be different in the newborn infant. Therefore echo studies are commonly performed in the neonatal cardiac evaluation. Some important aspects of normal and abnormal findings in physical examination, electrocardiograpgy (ECG), and chest x-ray

with esophageal atresia and severe esophageal reflux. Cyanosis that disappears with crying may signify choanal atresia.

#### **a. Respiratory diseases**

	- a. Hyaline membrane disease
	- b. Transiet tachypnea of the newborn
	- c. Pneumonia
	- d. Meconium aspiration

#### **b. Cardiac diseases**


#### **c. CNS diseases**

Periventricular-intraventricular hemorrhage, meningitis and primary seizure disorder can all cause cyanosis. Neuromuscular disorders such as Werdnong-Hoffmanndisease and congenital myotonic dystrophy can cause cyanosis.

#### **d. Other disorders**


Table 1. Differential diagnosis of cyanosis in the newborn

### **3.4 Is there differential cyanosis?**

If there is cyanosis of upper or lower part of the body only, this usually signifies serious heart disease. The more common pattern is cyanosis restricted to the lower part of the body, which is seen in patients with patent ductus arteriosus with left-to right shunt. Cyanosis restricted to the upper half of the body is seen occasionally in patients with pulmonary hypertension, patent ductus arteriosus, coarctation of aorta and D-transposition of great arteries.
