**6. Suggested approach to neonates with central cyanosis**

a. Although a significant heart murmur usually suggests a cardiac basis for the cyanosis, several of the more severe cardiac defects (transposition of the great vessels) may not initially be associated with a murmur.

Heart murmurs.

	- a. Pulmonary flow murmur is most common. It is more often found in premature and small-for-gestational-age infants than in full-term infants. A soft systolic murmur ( grade 1 to 2/6), heard best at the upper left sternal border (ULSB), transmits well to bozh sides of the chest, axillae, and the back.
	- b. Transient systolic murmur of PDA is soft ( grade 1 to 2/6), audible at the ULSB and in the left infraclavicular area on the first day. It usually disappears shortly thereafter.
	- c. Transient systolic murmur of tricuspid regurgitation is indistinguishable from that of VSD and is most common in infants who had fetal distress or neonatal asphyxia.
	- d. Vibratory systolic innocent murmur is a counterpart of Still's murmur in older children. It is audible at the LLSB, apex, or midprecordium.

Evaluation and Emergency Treatment of

**a. Structural heart defects** 

Critical AS or PS Preductal COA **b. Noncardiac causes** 

4. Neonatal sepsis

**d. Disturbances in heart rate** 

2. Atrial flutter or fibrillation

Table 2. Cause of heart failure in the neonate

**8. Hypoplastic left heart syndrome** 

b. Pathology and pathophysiology

from CHD during the first month of life.

**c. Myocardial disease**  1. Myocarditis

Large systemic AV fistula

Large PDA in premature infant

Hypoplastic left heart syndrome (HLHS) Severe tricuspid or pulmonary regurgitation

2. Metabolic: hypoglycemia, hypocalcemia 3. Severe anemia (as seen in hydrops fetalis)

paroxysmal atrial tachycardia(PAT))

5. Overtransfusion or overhydration

At birth

Week 1 TGA

Week 1-4

**7. Heart failure in the newborn infant** 

Criticlly Ill Neonate with Cyanosis and Respiratory Distress 241

The clinical picture of CHF in the neonate may simulate another disorder such as meningitis, sepsis, pneumonia, or bronchiolitis. Tachypnea, tachycardia, pulmonary crackles or rhonchi, hepatomegaly, and weak peripheral pulses are common presenting signs. Heart murmur is either faint or absent. Cardiomegaly on chest x-ray film is always present, with or without increased PVMs or pulmonary edema. Causes of CHF in the neonate are listed in Table 2.

Total anomalous pulmonary venous return (TAPVR) below diaphragm

1. Birth asphyxia (resulting in transient myocardial ischemia)

2. Transient myocardial ischemia ( with or without birth asphyxia)

1. Supravetricular tachycardia (supraventricular tachycardia (SVT) or

Two important CHDs that present with CHF in the newborn period are hypoplastic left heart syndrome (HLHS) and large PDA in premature infants. Transient myocardial

a. Prevalence:HLHS occurs in 1% of all CHDs and is the most common cause of death

3. Catdiomyopathy ( seen in infants of diabetic mothers)

3. Congenital heart block ( when associated with CHD)

The time of onset of CHF varies rather predictably with the type of CHD.

ischemia and infants of diabetic mothers are other causes of CHF in the neonate.


Even in the absence of a murmur, a newborn infant may have a serious heart defect that requires immediate attention, e.g., severe cyanotic heart disease such as TGA or pulmonary atresia with a closing PDA. Infants who are in severe CHF may not have a loud murmur until the myocardial function is improved with anticongestive measures.

