Temperature regulation can also be altered in infants with hypoxic–ischemic injury In patients presenting with hypoxia–ischemia (e.g., after cardiac arrest), fever should be aggressively prevented because hyperthermia can worsen neurologic injury COLOR CHANGES AND DERMATOLOGIC FINDINGS Goals of Emergency Care The goal is to recognize the difference between benign presentations, such as acrocyanosis, and life-threatening conditions, such as true cyanosis and pallor KEY POINTS Evaluation of jaundice requires assessment of both direct and indirect bilirubin Acceptable levels of indirect hyperbilirubinemia depend on both prematurity and postnatal age Many neonates with herpes simplex virus (HSV) infection have a negative maternal history of HSV RELATED CHAPTERS Signs and Symptoms Cyanosis: Chapter 21 Jaundice: Conjugated Hyperbilirubinemia and Jaundice: Unconjugated Hyperbilirubinemia: Chapters 44 and 45 Pallor: Chapter 62 Rash: Neonatal: Chapter 69 Septic-Appearing Infant: Chapter 73 Medical, Surgical, and Trauma Emergencies Cardiac Emergencies: Chapter 86 Dermatologic Urgencies and Emergencies: Chapter 88 The Children’s Hospital of Philadelphia Clinical Pathways ED Pathway for Evaluation/Treatment of Neonates Hyperbilirubinemia/Jaundice URL: https://www.chop.edu/clinical-pathway/hyperbilirubinemiajaundice-neonatal-clinical-pathway Authors: D Aronson, MD; J Lavelle, MD; C Jacobstein, MD; N Boorstein, RN Posted: October 2009, last revised January 2018 With ED Clinical Pathway for Evaluation/Treatment of Febrile Young Infants (0–56 Days Old) URL: https://www.chop.edu/clinical-pathway/febrile-infant-emergentevaluation-clinical-pathway Authors: R Scarfone, MD; P Gala, MD; A Murray, MD; M.K Funari, RN; J Lavelle, MD; L Bell, MD; C Jacobstein, MD Posted: August 2010, last revised August 2019 Color Changes Cyanosis CLINICAL PEARLS AND PITFALLS Cyanosis may not be visible toward the end of the neonatal period because of physiologic anemia Benign acrocyanosis may involve the perioral region but spares the lips and mucous membranes Diarrheal illness and/or dehydration can lead to acquired methemoglobinemia Current Evidence Cyanosis refers to a blue tone visible in the skin and mucous membranes, caused by desaturated or abnormal hemoglobin The human eye can detect cyanosis when there is at least g/dL of reduced hemoglobin Therefore, hemoglobin oxygen desaturation may be missed if there is anemia Conversely, abnormal hemoglobin may be saturated with oxygen yet unable to release to the tissues, resulting in visible cyanosis Methemoglobinemia is a classic example of this situation Central cyanosis is caused by deoxygenated blood entering the systemic circulation This is usually due to CHD, specifically cardiac defects allowing systemic venous blood to bypass the lungs (right-to-left shunt), but central cyanosis may also be caused by respiratory compromise or pharmacologic agents Acrocyanosis, the transient blue discoloration of the hands and feet in response to vasomotor instability or a cool environment, is caused by vasoconstriction of the small arterioles and does not reflect reduced systemic arterial oxygenation Mottling is the patchy-colored appearance of the body surface, resulting from dilation of the superficial veins showing through the thin neonatal skin Goals of Treatment The goals of ED evaluation of the cyanotic infant include early recognition of cardiorespiratory pathology or pharmacologic causes Clinical Considerations Clinical Recognition Proper lighting is important to assess cyanosis in neonates Location of cyanosis helps determine its cause Cyanosis noted in the mucous membranes, tongue, trunk, and extremities is central In contrast, acrocyanosis is limited to hands, feet, and perioral region, with the tongue and rest of skin remaining pink This condition may be associated with cool ambient temperature Acrocyanosis is benign and may resolve with warming Local blue discoloration of a single extremity could be the result of compromised distal circulation A local blue hue to skin may also be the result of pigment from blue clothing dye Triage Consideration “Blue babies” should be evaluated promptly for cardiorespiratory disease The degree of oxygen desaturation associated with cyanosis should be documented by pulse oximetry Clinical Assessment When obtaining history, relevant questions include the following: When was the color change first noted? Is it persistent or intermittent? For example, choanal atresia will cause cyanosis at rest, which improves with crying, whereas the cyanosis of congenital cardiac disease will often worsen with crying because of increased pulmonary vascular resistance Does the cyanosis improve with oxygen? Are there other accompanying symptoms? In cyanotic cardiac disease (i.e., right-to-left shunt), the breath sounds will be normal with symmetric chest excursion In contrast an infant with cyanosis due to pulmonary disease or congestive heart failure will have wheezes or crackles and accessory chest muscle use With pulmonary disease or congestive heart failure, the increase in saturation may be dramatic when the infant receives increased oxygen (see hyperoxia test, under Section: Neonatal Cardiac Emergencies) Cyanosis accompanied by mottling in a lethargic neonate with tachycardia indicates shock Sepsis, hypovolemia, intra-abdominal surgical emergency, and metabolic crisis from inborn errors of metabolism (IEM) should be considered in addition to primary cardiorespiratory problems Early recognition and volume resuscitation are critical for treatment Methemoglobinemia is characterized by a cyanotic infant without underlying cardiac or pulmonary disease The infant can look cyanotic to gray, with an almost normal-appearing pulse oximetry Supplemental oxygen will not alter the color Methemoglobinemia is confirmed by venous or capillary blood gas or the persistence of a chocolate-brown color of a blood drop on filter paper Initial treatment is first searching and removing the offending agent, which is most often topical anesthetic agents, aniline dyes, and high levels of nitrate in the water supplies Levels of methemoglobinemia above 20% are associated with clinical symptoms If methemoglobinemia is greater than 30% of total hemoglobin, consider a dose of methylene blue, to mg/kg, given over minutes Jaundice CLINICAL PEARLS AND PITFALLS Jaundice within the first 24 hours of life is pathologic Evaluation of jaundice requires assessment of both direct and indirect bilirubin Acceptable levels of indirect hyperbilirubinemia depend on both prematurity and postnatal age Acute bilirubin toxicity results in lethargy and progressive encephalopathy in the neonate Untreated, persistent bilirubin encephalopathy results in kernicterus, a permanent brain injury Galactosemia should be considered in infants who have jaundice that persists beyond weeks of age Current Evidence Jaundice is a yellow appearance of the skin or sclera caused by elevated bilirubin levels Bilirubin accumulates with excessive hemolysis, failure of hemoglobin to conjugate with glucuronic acid in the liver, or inadequate excretion through the liver canaliculi or bile ducts Unconjugated bilirubin is reported as indirect, and indicates excessive red blood cell hemolysis or inability of the liver to keep pace with conjugation of bilirubin produced by hemolysis ... lethargic neonate with tachycardia indicates shock Sepsis, hypovolemia, intra-abdominal surgical emergency, and metabolic crisis from inborn errors of metabolism (IEM) should be considered in addition