Pulse oximetry and arterial saturation bias in neonates: retrospective analysis by race & ethnicity

To examine the accuracy of pulse oximetry in neonates by race and ethnicity.

We performed a single-centre retrospective cross-sectional study in neonates aged ≤ 7 days at Children's Healthcare of Atlanta in the neonatal and cardiac ICU between 2010 and 2022. Eligible patients had pulse oximetry with arterial oxygen saturation measurements taken within 10 minutes. We evaluated the mean saturation bias, accuracy root mean square, and the frequency of occult hypoxaemia by race and ethnicity.

Of 1645 infants, there were 639 non-Hispanic Black infants (38.8%), 651 non-Hispanic White infants (39.6%), and 215 Hispanic infants (13.1%). The majority had no CHD (71.4%), required respiratory support (81.1%), and had oxygen saturation levels = > 90% (87.6%). The mean pulse oximetry and arterial oxygen measurement time difference was 0.8 minutes. The mean bias and accuracy root mean square were 8.7% and 13.7%, respectively, with no significant difference between the groups (p = 0.91). Occult hypoxaemia was found in 20.5% of infants. Compared to White infants, there were no differences in likelihood of occult hypoxaemia for either Black (adjusted prevalence ratio 1.13 (0.92-1.4), p = 0.24) or Hispanic (1.06 (0.77-1.45, p = 0.72) infants.

There was not a systemic discrepancy in pulse oximetry between racial and ethnic groups as previously described in older children and adults. However, pulse oximetry significantly overestimated arterial oxygen saturation. Future prospective studies that objectively measure skin pigmentation may be able to overcome some of the limitations of our study.