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You receive a report that an infant “doesn’t look good” or looks “mottled.” Other descriptors may include “poor perfusion” or “washed-out appearance.” This can include pallor, which can be seen in poor perfusion or may be an early sign of hypoxia or anemia. Most of these terms refer to poor perfusion and imply there is inadequate blood flow to the tissues of the skin. Assessing peripheral tissue perfusion is important in the clinical examination of a neonate since it can help determine who may have low systemic blood flow or cardiovascular failure. Recent studies have shown correlations between poor outcomes and peripheral hypoperfusion in preterm infants.


  1. What is the age of the infant? Hypoplastic left heart syndrome (HLHS) may cause poor perfusion and a mottled appearance. It may be seen at days 1 to 21 of life (more commonly at day 2 or 3). In an infant <3 days old (some definitions say <7 days) early-onset sepsis may be a cause. Associated risk factors for sepsis are premature rupture of membranes, maternal infection, and fever. Late-onset sepsis can occur at >3 days or after 7 days, depending upon which definition is used.

  2. What are the vital signs? If the temperature is lower than normal, cold stress or hypothermia associated with sepsis may be present. Hypotension may cause poor perfusion (see normal blood pressure values in Table 70–1 and Appendix C). Decreased urine output (<2 mL/kg/h) may indicate depleted intravascular volume or shock.

  3. Is the liver enlarged? Are metabolic acidosis, poor peripheral pulse rate, and a gallop present? These problems are signs of failure of the left side of the heart (eg, HLHS). Poor perfusion occurs because of reduced blood flow to the skin.

  4. If mechanical ventilation is being used, are chest movements adequate and are blood gas levels improving? Inadequate ventilation can result in poor perfusion.

  5. Is the poor perfusion localized to only 1 area of the body? Aortic thrombosis can present with weak femoral pulses, coldness, and poor perfusion of the limbs.

  6. Are congenital anomalies present? Persistent cutis marmorata (see Section III.A.15) may be seen in Cornelia de Lange syndrome, cutis marmorata telangiectatica congenita (CMTC), Edward syndrome (trisomy 18), and Down syndrome (trisomy 21). Chromosome 22q11 deletion syndrome can present with abnormal vascular tone with hypotension. Cornelia de Lange syndrome consists of multiple congenital anomalies: a distinctive facial appearance, pre- and postnatal growth deficiency, feeding problems, psychomotor delay, behavioral problems, and malformations that mainly involve the upper extremities.


  1. Common causes

    1. Sepsis. Poor peripheral perfusion is seen as an early sign of sepsis.

    2. Cold stress/hypothermia. In general, associated with a skin temperature <36.5°C (97.7°C).

    3. Hypotension usually with shock.

    4. Hypoventilation can cause poor perfusion.

    5. Respiratory distress syndrome. Infants with respiratory distress syndrome have poor perfusion and lower perfusion index.

    6. Apnea/apnea of prematurity can cause a decrease in peripheral ...

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