Pulse oximetry in pediatric care: Balancing advantages and limitations

Table 1 The challenges facing using pulse oximetry in children and how to overcome them

Problem	Suggested solution
Children have smaller fingers and earlobes	Use specialized sensors designed for pediatric use. These are smaller in size and may include adhesive attachments to secure them properly on the child’s finger, toe, or other appropriate site
Increased risk of movement during monitoring	Ensure careful positioning of the sensor and minimize patient movement during measurement to prevent motion artifacts that could affect the accuracy of pulse oximetry readings
Variation in skin pigmentation	Be aware that darker skin tones can absorb more light, potentially leading to lower readings. If necessary, consider appropriate adjustments or alternative monitoring sites to account for skin pigmentation differences
Lower peripheral perfusion in pediatric patients	Choose a monitoring site with better perfusion or use pulse oximetry in conjunction with clinical assessment to ensure accurate monitoring, especially in neonates and infants
Specific calibration settings for pediatric oximeters	Ensure that pulse oximeters used in pediatric settings are appropriately calibrated to obtain accurate readings, with calibration settings tailored to the age and size of the patient population
Consideration of clinical factors in interpretation	Contextualize SpO2 readings within the overall clinical picture, considering the child’s age, clinical condition, and baseline oxygen saturation levels for accurate assessment and appropriate intervention

SpO₂: Oxygen saturation.

Table 2 The preferred placement sites for pulse oximeter probes in neonates, infants, and children

Age group	Preferred placement sites
Neonates	The palm of the hand (preferred)
	Sole of the foot (if palm reading is difficult)
	Wrist
	Ankle
Infants	Finger (index finger preferred, followed by thumb, middle finger, and great toe), nose, earlobe, forehead
Children	Finger (index finger preferred, followed by thumb, middle finger, and great toe), nose, earlobe, forehead

Table 3 Clinical indications of pulse oximetry in neonates, infants, and children

Clinical application	Description
Neonatal indications
Fetal and neonatal care	Pulse oximetry can continuously monitor oxygen saturation during delivery and in neonates with respiratory distress syndrome, congenital heart defects, or other respiratory conditions
Newborn screening for CCHD	Pulse oximetry screening detects CCHD in newborns by comparing SpO2 readings between the upper and lower extremities, indicating the presence of heart defects
RDS	Pulse oximetry assesses oxygenation and monitors respiratory status in preterm infants with RDS, guiding oxygen therapy and evaluating response to treatment
BPD	Pulse oximetry monitors oxygenation and respiratory status in infants with BPD, guiding oxygen therapy, detecting complications, and assessing response to interventions
Apnea of prematurity	Pulse oximetry detects oxygen desaturation events associated with apnea in premature infants, allowing for prompt intervention and monitoring of respiratory status
PPHN	Pulse oximetry assesses oxygenation and monitors response to treatment in infants with PPHN, guiding oxygen therapy and evaluating the effectiveness of interventions
Neonatal methemoglobinemia	Pulse oximetry may underestimate O2 saturation in neonatal methemoglobinemia, prompting further investigation and monitoring of response to treatment
Postoperative care	Pulse oximetry monitors O2 saturation levels in neonates after surgery, facilitating early detection of respiratory compromise & guiding interventions for optimal recovery
Infancy and childhood indications
Children with respiratory illnesses	Pulse oximetry is essential for managing respiratory illnesses in children. It aids in assessing oxygen saturation levels and the severity of the condition, monitoring oxygen therapy effectiveness, tracking treatment response, and guiding clinical decisions. It provides valuable insights into conditions like pneumonia, bronchiolitis, and asthma exacerbations
Assessment of circulatory status	Pulse oximetry is significant in evaluating circulatory status in children. It allows for the early detection of circulatory compromise and guides interventions to restore perfusion and prevent organ dysfunction. It also provides real-time feedback on treatment effectiveness, particularly in cases of shock or hypovolemia
Monitoring during anesthesia and sedation	Pulse oximetry is crucial for monitoring children during anesthesia and sedation. It enables continuous assessment of SpO2 levels and pulse rate. It aids in the early detection of respiratory depression, airway obstruction, and hypoxemia, ensuring patient safety during procedures requiring anesthesia or sedation
Management of sleep disorders	Pulse oximetry is instrumental in managing childhood sleep disorders such as OSA or central sleep apnea. It facilitates screening, assesses severity, monitors treatment effectiveness, and detects complications. It also enables home monitoring, leading to early treatment failure or disease progression detection
Evaluation of trauma and critical care	Pulse oximetry assists in the rapid assessment of oxygenation status in children with trauma or critical illness, aiding in the early detection of hypoxemia and respiratory compromise. It provides continuous monitoring during critical care interventions and facilitates timely escalation of care
Home monitoring	Pulse oximetry is valuable for monitoring various childhood disorders at home, including respiratory conditions, congenital heart diseases, neurological disorders, and neonatal complications. It enables early detection of abnormalities, prompts medical attention, and enhances accessibility to healthcare services when integrated with telemedicine technologies

BPD: Bronchopulmonary dysplasia; CCHD: Critical congenital heart disease; OSA: Obstructive sleep apnea; PPHN: Persistent pulmonary hypertension of the newborn; RDS: Respiratory distress syndrome; SpO₂: Oxygen saturation.

Table 4 The diseases or conditions, the problems they pose to pulse oximetry, and potential solutions to address these challenges

Disease/condition	Problem with pulse oximetry	Solution
Anaemia	Reduced accuracy of SpO2 readings due to lower hemoglobin levels affecting oxygen saturation	Interpret readings cautiously, consider other clinical indicators, and perform arterial blood gas analysis for severe cases
Polycythaemia	Falsely elevated SpO2 readings due to increased hemoglobin levels and altered blood viscosity	Be aware of potential inaccuracies and consider alternative assessment methods, such as arterial blood gas analysis
Metabolic derangement	Shifts in the oxygen dissociation curve and peripheral vasoconstriction can affect SpO2 readings	Interpret readings cautiously, consider other clinical parameters, and be aware of acidosis-induced left shifts or alkalosis-induced right shifts
Cardiac arrhythmia	Irregular blood flow causes fluctuations in pulsatile signal, leading to inaccurate readings	Use pulse oximeters with advanced signal processing algorithms, monitor waveform quality, and consider alternative assessments such as arterial blood gas analysis
Hypothermia	Reduced peripheral perfusion and altered oxygen dissociation curve affecting SpO2 accuracy	Apply local heating to improve perfusion, use pulse oximeters with enhanced low-perfusion algorithms, and consider supplemental assessments
Jaundice	Minimal interference from bilirubin with pulse oximetry readings, though COHb may cause inaccuracies	Monitor for COHb levels in severe cases; rely on pulse oximetry for most jaundiced patients
Electromagnetic field	Interference with pulse oximetry readings from sources such as electrosurgical units and cellular phones	Use fiberoptic pulse oximetry during MRI procedures to minimize exposure to electromagnetic fields

COHb: Carboxyhemoglobin; MRI: Magnetic resonance imaging; SpO₂: Oxygen saturation.

Table 5 General guidelines for effective use of pulse oximetry

Guideline	Details
Sensor placement	Place on well-perfused areas (finger, toe, earlobe) based on the child’s age and size
Sensor securement	Secure snugly but not too tightly to prevent motion artifacts and ensure optimal signal quality
Establish baseline	Establish a baseline oxygen saturation level for each patient to interpret subsequent readings accurately
Considerations	The expected oxygen saturation range should be determined based on age, baseline respiratory status, and underlying medical conditions
Continuous monitoring	Continuous monitoring should be used in critically ill or high-risk patients to promptly detect changes in oxygen saturation
Additional parameters	Monitor respiratory rate, heart rate, level of consciousness, and skin color alongside oxygen saturation levels
Minimizing artifacts	Minimize patient movement, ensure proper sensor placement, and use immobilization techniques or sedation as needed to reduce motion artifacts
Equipment maintenance	Regularly monitor and address technical issues and calibrate equipment according to manufacturer’s guidelines
Sensor replacement	Replace sensors as needed to maintain accuracy and reliability
Alternative sites	Alternative sensor placement sites (forehead or palm) should be used for patients with poor peripheral perfusion or compromised circulation
Trend monitoring	Monitor trends in oxygen saturation over time rather than relying solely on individual readings
Education	Educate parents, caregivers, and healthcare staff about the importance of pulse oximetry and proper sensor placement
Documentation	Document pulse oximetry readings, relevant clinical information, and interventions in the patient’s medical record
Optimization	Every effort should be made to optimize pulse oximetry monitoring effectiveness, improving patient outcomes and care quality