Is perioral cyanosis normal in infants with periodic breathing?

Perioral Cyanosis in Infants with Periodic Breathing

Perioral cyanosis is not normal in infants with periodic breathing and warrants immediate evaluation as it indicates significant hypoxemia that can lead to adverse outcomes including neurodevelopmental issues and increased risk for brief resolved unexplained events (BRUEs). 1

Understanding Periodic Breathing and Oxygenation

• Periodic breathing is a common respiratory pattern in preterm infants, characterized by three or more sequential apneas each lasting ≥3 seconds 2
• While periodic breathing itself is considered a normal immature breathing pattern, it should not cause significant hypoxemia or cyanosis 3
• During periodic breathing, infants are at higher risk for desaturation episodes, with studies showing all infants experiencing episodes where SpO₂ falls ≥5% during periodic breathing 4
• The slope of desaturation during periodic breathing is approximately twice as steep compared to non-periodic breathing, leading to more rapid drops in oxygen saturation 5

Clinical Significance of Perioral Cyanosis

• Perioral cyanosis indicates that oxygen saturation has fallen below 80-85%, which is significantly below the recommended safe range of 90-95% for infants 1
• The American Thoracic Society recommends maintaining oxygen saturations above 92% during sleep for infants with respiratory issues 6
• Hypoxemia during periodic breathing can lead to:
  • Pulmonary hypertension and right ventricular hypertrophy 1
  • Neurodevelopmental delays and cognitive impairment 1
  • Increased risk for BRUEs and potentially sudden infant death 1
  • Sleep fragmentation and decreased REM sleep 1

Evaluation of Infants with Perioral Cyanosis

• Infants showing perioral cyanosis during periodic breathing require prompt assessment for:
  • Underlying cardiopulmonary conditions including congenital heart disease 1
  • Chronic lung disease of infancy 1
  • Sleep-disordered breathing or obstructive sleep apnea 1
  • Gastroesophageal reflux disease, which can present with cyanosis and respiratory distress 7
  • Abnormal peripheral chemoreceptor function, which is common in infants with chronic lung disease 1

Management Recommendations

• Continuous monitoring of oxygen saturation is essential for infants exhibiting perioral cyanosis 1
• Supplemental oxygen should be provided to maintain SpO₂ between 90-95%, as this range:
  • Reduces pulmonary artery pressure 1
  • Decreases frequency of central apnea 1
  • Improves sleep quality and promotes growth 1
• Monitoring should be performed during various states including sleep, feeding, and activity 1
• Infants may require continued nighttime oxygen supplementation even after daytime oxygen has been discontinued 1

Important Considerations and Pitfalls

• Relying solely on clinical observation without oxygen saturation monitoring can miss significant desaturation episodes 1
• Infants with chronic lung disease may have blunted responses to hypoxia, making them unable to recover from hypoxic episodes without intervention 1
• Failure to maintain adequate oxygenation in infants with periodic breathing can lead to long-term complications including pulmonary hypertension and neurodevelopmental issues 1
• Perioral cyanosis may be the first sign of more serious conditions such as sepsis, necrotizing enterocolitis, or cardiac disease 3, 7