Racial discrepancy in pulse oximeter accuracy in preterm infants
Open accessAbstract
Objective Pulse oximetry is commonly used in Neonatology, however recent adult data suggest racial disparity in accuracy, with overestimation of oxygen saturation for Black patients.Study design Black and White infants <32 weeks gestation underwent simultaneous arterial blood gas and pulse oximetry measurement. Error by race was examined using mean bias, A rms, Bland-Altman, and linear/non-linear analysis.Results A total of 294 infants (124 Black, 170 White) were identified with mean GA of 25.8 ± 2.1 weeks and mean BW of 845 ± 265 grams, yielding 4387 SaO 2-SpO 2 datapoints. SpO 2 overestimation, measured by mean bias, was 2.4-fold greater for Black infants and resulted in greater occult hypoxemia (SpO 2 > 90% when SaO 2 < 85%; 9.2% vs. 7.7% of samples). Sensitivity and specificity for detection of true hypoxemia were similar between groups (39 vs. 38%; 81 vs. 78%).Conclusion There is a modest but consistent difference in SpO 2 error between Black and White infants, with increased incidence of occult hypoxemia in Black infants.
The claims and statistics of this paper haven’t been checked yet.
Run the check — free, no account needed. It reads the open-access text and checks the sources it cites.
Integrity signals
Registry
Cites
Statistics
Claims the paper makes
The claims and statistics of this paper haven’t been checked yet.
Run the check — free, no account needed. It reads the open-access text and checks the sources it cites.
Claims other papers make about this one
Each is checked against this paper’s own text: does it say what the citing paper says it does?
More recent studies have revealed that dark skin pigmentation influences the accuracy and performance of pulse oximeter devices, resulting in overestimations, with increased incidence in the risk for occult hypoxemia (SO2<88% despite normal SpO2>92%).
“More recent studies have also revealed that dark skin pigmentation influences the accuracy and performance of pulse oximeters devices, resulting in overestimations [17,49,50,51,52,53] with increased incidence in the risk for occult hypoxemia (SO2<88% despite normal SpO2>92%) [54,55].”
From Skin pigmentation influence on pulse oximetry accuracy: a systematic review and bibliometric analysis (2022) · cites this paper as [51]
Recent studies have shown a positive bias in oxygen saturation measurements in patients with darkly pigmented skin, particularly under low saturation conditions.
“Recent studies have shown a positive bias in oxygen saturation measurements in patients with darkly pigmented skin, particularly under low saturation conditions.”
From Skin pigmentation influence on pulse oximetry accuracy: a systematic review and bibliometric analysis (2022) · cites this paper as [51]
Ancestry descriptors were used in 11 studies (29.73%).
“On the other hand, ancestry descriptors were used in 11 studies (29.73%) [17,21,23,24,41,51,53,61,75,82,93]”
From Skin pigmentation influence on pulse oximetry accuracy: a systematic review and bibliometric analysis (2022) · cites this paper as [51]
Pulse oximetry performance in the dark-skinned population may lead to overestimations with increased incidence of occult hypoxemia and risk of negative health effects from diseases like COVID-19.
“To sum up, we conclude that pulse oximetry performance in the dark-skinned population may lead to overestimations with increased incidence of occult hypoxemia and risk of negative health effects from diseases like COVID-19 [51,53,55].”
From Skin pigmentation influence on pulse oximetry accuracy: a systematic review and bibliometric analysis (2022) · cites this paper as [51]
Two studies found a small but consistent skin pigmentation disparity in SpO2 measurements with values that may be falsely high in dark-skinned preterm infants.
“The other two studies found a small but consistent skin pigmentation disparity in SpO2 measurements with values that may be falsely high in dark-skinned preterm infants [51,74].”
From Skin pigmentation influence on pulse oximetry accuracy: a systematic review and bibliometric analysis (2022) · cites this paper as [51]
Self-check
Percentages, sums and reported differences re-computed from the paper’s own numbers.
The self-check needs the paper’s full text.
Cites
The validity and practicality of sun-reactive skin types I through VI
Fitzpatrick, T. B. (1988) · Archives of Dermatology · doi:10.1001/archderm.1988.01670060015008 · Cited by 4,339 · see citing works
Racial bias in pulse oximetry measurement
Sjoding, M. W., Dickson, R. P., Iwashyna, T. J., Gay, S. E., & Valley, T. S. (2020) · New England Journal of Medicine · doi:10.1056/nejmc2029240 · Cited by 1,114 · see citing works
Target Ranges of Oxygen Saturation in Extremely Preterm Infants
Shriver, E. K. (2010) · New England Journal of Medicine · doi:10.1056/nejmoa0911781 · Cited by 964 · see citing works
Intraventricular Hemorrhage in Premature Infants: Mechanism of Disease
Ballabh, P. (2009) · Pediatric Research · doi:10.1203/pdr.0b013e3181c1b176 · Cited by 784 · see citing works
Pulse oximetry: Understanding its basic principles facilitates appreciation of its limitations
Chan, E. D., Chan, M. M., & Chan, M. M. (2013) · Respiratory Medicine · doi:10.1016/j.rmed.2013.02.004 · Cited by 712 · see citing works
Zijlstra, W. G., Buursma, A., & Roest, W. P. M.-V. D. (1991) · Clinical Chemistry · doi:10.1093/clinchem/37.9.1633 · Cited by 669 · see citing works
The STOP-ROP Multicenter Study Group (2000) · PEDIATRICS · doi:10.1542/peds.105.2.295 · Cited by 659 · see citing works
Flynn, J. T., & Bancalari, E. (2000) · Journal of American Association for Pediatric Ophthalmology and Strabismus · doi:10.1067/mpa.2000.105823 · Cited by 620 · see citing works
Oxygen Saturation and Outcomes in Preterm Infants
The BOOST II United Kingdom, A. (2013) · New England Journal of Medicine · doi:10.1056/nejmoa1302298 · Cited by 507 · see citing works
Zonios, G., Bykowski, J., & Kollias, N. (2001) · Journal of Investigative Dermatology · doi:10.1046/j.0022-202x.2001.01577.x · Cited by 477 · see citing works
Pulse oximetry: fundamentals and technology update
Nitzan, M., Romem, A., & Koppel, R. (2014) · Medical Devices: Evidence and Research · doi:10.2147/mder.s47319 · Cited by 438 · see citing works
Effects of skin pigmentation on pulse oximeter accuracy at low saturation
Bickler, P. E., Feiner, J. R., & Severinghaus, J. W. (2005) · Anesthesiology · doi:10.1097/00000542-200504000-00004 · Cited by 427 · see citing works
Functional and pathological effects of prolonged hyperoxia in neonatal mice
Warner, B. B., Stuart, L. A., Papes, R. A., et al. (1998) · American Journal of Physiology-Lung Cellular and Molecular Physiology · doi:10.1152/ajplung.1998.275.1.l110 · Cited by 422 · see citing works
Feiner, J. R., Severinghaus, J. W., & Bickler, P. E. (2007) · Anesthesia & Analgesia · doi:10.1213/01.ane.0000285988.35174.d9 · Cited by 400 · see citing works
Luks, A. M., & Swenson, E. R. (2020) · Annals of the American Thoracic Society · doi:10.1513/annalsats.202005-418fr · Cited by 263 · see citing works
Fanaroff and Martin's Neonatal-Perinatal Medicine: Diseases of the Fetus and Infant
Martin, E. B. R. J., Fanaroff, A. A., & Walsh, M. C. (2010) · Medical Entomology and Zoology · Cited by 262 · see citing works
Clinical assessment of infant colour at delivery
O’Donnell, C. P., Kamlin, C. O. F., Davis, P. G., Carlin, J. B., & Morley, C. J. (2007) · Archives of Disease in Childhood Fetal & Neonatal · doi:10.1136/adc.2007.120634 · Cited by 262 · see citing works
Variations in skin colour and the biological consequences of ultraviolet radiation exposure
Bino, S. D., & Bernerd, F. (2013) · British Journal of Dermatology · doi:10.1111/bjd.12529 · Cited by 261 · see citing works
Whyte, R. K., Kirpalani, H. M., Asztalos, E. V., et al. (2008) · PEDIATRICS · doi:10.1542/peds.2008-0338 · Cited by 221 · see citing works
Neonatal and Pediatric Pulse Oximetry
Salyer, J. W. (2003) · Respiratory Care · doi:10.4187/respcare.03480386 · Cited by 183 · see citing works
Reliability of Conventional and New Pulse Oximetry in Neonatal Patients
Hay, W. W., Rodden, D., Collins, S. M., et al. (2002) · Journal of Perinatology · doi:10.1038/sj.jp.7210740 · Cited by 172 · see citing works
Ries, A. L., Prewitt, L. M., & Johnson, J. J. (1989) · Chest · doi:10.1378/chest.96.2.287 · Cited by 145 · see citing works
Cytokines in tolerance to hyperoxia-induced injury in the developing and adult lung
Bhandari, V., & Elias, J. A. (2006) · Free Radical Biology and Medicine · doi:10.1016/j.freeradbiomed.2006.01.027 · Cited by 145 · see citing works
Neonatal Pulse Oximetry: Accuracy and Reliability
Hay, W. W., Brockway, J., & Eyzaguirre, M. (1989) · PEDIATRICS · doi:10.1542/peds.83.5.717 · Cited by 141 · see citing works
Perkins, G. D., McAuley, D. F., Giles, S., Routledge, H., & Gao, F. (2003) · Critical Care · doi:10.1186/cc2339 · Cited by 136 · see citing works
Accuracy of Pulse Oximetry in Children
Ross, P. A., Newth, C. J. L., & Khemani, R. G. (2014) · Pediatrics · doi:10.1542/peds.2013-1760 · Cited by 129 · see citing works
Blood gas analysis: effect of air bubbles in syringe and delay in estimation.
Biswas, C. K., Ramos, J. M., Agroyannis, B. J., et al. (1982) · BMJ · doi:10.1136/bmj.284.6320.923 · Cited by 123 · see citing works
Alexander, G. R., Wingate, M. S., Bader, D., & Kogan, M. D. (2007) · American Journal of Obstetrics and Gynecology · doi:10.1016/j.ajog.2007.06.006 · Cited by 116 · see citing works
Racial disparity in infant mortality
Matoba, N., & Collins, J. W. (2017) · Seminars in Perinatology · doi:10.1053/j.semperi.2017.07.003 · Cited by 105 · see citing works
Spectral Responses of Melanin to Ultraviolet A Irradiation
Ou‐Yang, H., Stamatas, G. N., & Kollias, N. (2004) · Journal of Investigative Dermatology · doi:10.1046/j.0022-202x.2004.22247.x · Cited by 104 · see citing works
Pulse oximetry for monitoring infants in the delivery room: a review
Dawson, J. A., Davis, P. G., O’Donnell, C. P., et al. (2006) · Archives of Disease in Childhood Fetal & Neonatal · doi:10.1136/adc.2006.102749 · Cited by 102 · see citing works
Effect of skin pigmentation on pulse oximetry accuracy in the emergency department
Adler, J. N., Hughes, L. A., Vtvilecchia, R., & Jr., C. A. C. (1998) · Academic Emergency Medicine · doi:10.1111/j.1553-2712.1998.tb02772.x · Cited by 102 · see citing works
A Change in Oxygen Supplementation Can Decrease the Incidence of Retinopathy of Prematurity
Sears, J. E., Pietz, J., Sonnie, C., et al. (2009) · Ophthalmology · doi:10.1016/j.ophtha.2008.09.051 · Cited by 96 · see citing works
The Effect of Skin Pigmentation on the Accuracy of Pulse Oximetry in Infants with Hypoxemia
Foglia, E. E., Whyte, R. K., Chaudhary, A., Mott, A., Chen, J., Propert, K. J., & Schmidt, B. (2017) · The Journal of Pediatrics · doi:10.1016/j.jpeds.2016.11.043 · Cited by 96 · see citing works
Anderson, J. G., Rogers, E. E., Baer, R. J., et al. (2017) · Neonatology · doi:10.1159/000480536 · Cited by 88 · see citing works
Hyperoxemia in Newborn Infants: Detection by Pulse Oximetry
Bucher, H.-U., Fanconi, S., Baeckert, P., et al. (1989) · PEDIATRICS · doi:10.1542/peds.84.2.226 · Cited by 86 · see citing works
Pulse Oximetry in Very Low Birth Weight Infants With Acute and Chronic Lung Disease
Ramanathan, R., Durand, M., & Larrazabal, C. (1987) · PEDIATRICS · doi:10.1542/peds.79.4.612 · Cited by 76 · see citing works
Postnatal Fetal and Adult Hemoglobin Synthesis in Early Preterm Newborn Infants
Bard, H. (1973) · Journal of Clinical Investigation · doi:10.1172/jci107360 · Cited by 72 · see citing works
Batchelder, P. B., & Raley, D. M. (2007) · Anesthesia & Analgesia · doi:10.1213/01.ane.0000268495.35207.ab · Cited by 62 · see citing works
Validation of Oxygen Saturation Monitoring in Neonates
Shiao, S.-Y. P. K., & Ou, C. (2007) · American Journal of Critical Care · doi:10.4037/ajcc2007.16.2.168 · Cited by 61 · see citing works
Rosychuk, R. J., Hudson-Mason, A., Eklund, D., et al. (2011) · Neonatology · doi:10.1159/000326797 · Cited by 55 · see citing works
Detection of hyperoxaemia in neonates: data from three new pulse oximeters
Bohnhorst, B., Peter, C. S., & Poets, C. F. (2002) · Archives of Disease in Childhood Fetal & Neonatal · doi:10.1136/fn.87.3.f217 · Cited by 51 · see citing works
Fanaroff and Martin's neonatal-perinatal medicine diseases of the fetus and infant
Martin, R. J. 1., Fanaroff, A. A., & Walsh, M. C. (2015) · Cited by 51 · see citing works
Melanin as a confounding factor in near infrared spectroscopy of skin
Matas, A., Sowa, M. G., Taylor, G., & Mantsch, H. H. (2002) · Vibrational Spectroscopy · doi:10.1016/s0924-2031(01)00144-8 · Cited by 50 · see citing works
Absorption characteristics of human fetal hemoglobin at wavelengths used in pulse oximetry
Harris, A. P., SENDAK, M. J., Donham, R. T., et al. (1988) · Journal of Clinical Monitoring and Computing · doi:10.1007/bf01621812 · Cited by 49 · see citing works
Reliability of a pulse oximeter in the detection of hyperoxemia
Poets, C. F., Wilken, M., Seidenberg, J., Southall, D. P., & von der Hardt, H. (1993) · The Journal of Pediatrics · doi:10.1016/s0022-3476(05)83494-8 · Cited by 47 · see citing works
A Comparison of the Melanocyte Response to Narrow Band UVA and UVB Exposure In Vivo
Rosen, C. F., Seki, Y., Farinelli, W. A., Stern, R. S., Fitzpatrick, T. B., Pathak, M. A., & Gange, R. W. (1987) · Journal of Investigative Dermatology · doi:10.1111/1523-1747.ep12470474 · Cited by 45 · see citing works
Whyte, R. K. (2012) · Seminars in Perinatology · doi:10.1053/j.semperi.2012.04.010 · Cited by 44 · see citing works
Operational Evaluation of Pulse Oximetry in NICU Patients with Arterial Access
Gerstmann, D. R., Berg, R., Haskell, R., et al. (2003) · Journal of Perinatology · doi:10.1038/sj.jp.7210944 · Cited by 41 · see citing works
In vivo spectroscopy of jaundiced newborn skin reveals more than a bilirubin index
Randeberg, L. L., Roll, E. B., Nilsen, L. T. N., et al. (2005) · Acta Paediatrica · doi:10.1111/j.1651-2227.2005.tb01790.x · Cited by 40 · see citing works
Early hypoxemia burden is strongly associated with severe intracranial hemorrhage in preterm infants
Vesoulis, Z. A., Bank, R. L., Lake, D., et al. (2018) · Journal of Perinatology · doi:10.1038/s41372-018-0236-2 · Cited by 40 · see citing works
Self-citationPhilip, K. E. J., Bennett, B., Fuller, S., Lonergan, B., McFadyen, C., Burns, J., Tidswell, R., & Vlachou, A. (2020) · BMJ Open Respiratory Research · doi:10.1136/bmjresp-2020-000778 · Cited by 35 · see citing works
Skin reflectance of newborn infants from 25 to 44 weeks gestational age.
Pw, P., Krauss, A. N., Walcman, S., et al. (1976) · PubMed · Cited by 33 · see citing works
Burden of hypoxia and intraventricular haemorrhage in extremely preterm infants
Ng, I. H. X., da Costa, C. S., Zeiler, F. A., Wong, F. Y., Smielewski, P., Czosnyka, M., & Austin, T. (2019) · Archives of Disease in Childhood Fetal & Neonatal · doi:10.1136/archdischild-2019-316883 · Cited by 23 · see citing works
Skin Reflectance of Newborn Infants from 25 to 44 Weeks Gestational Age
Post, P. W., Krauss, A. N., Waldman, S., et al. (2020) · Human Biology · Cited by 23 · see citing works
Phillips, H. M., Holland, B. M., Jones, J. G., et al. (1988) · Pediatric Research · doi:10.1203/00006450-198806000-00013 · Cited by 22 · see citing works
Harnessing color vision for visual oximetry in central cyanosis
Changizi, M. A., & Rio, K. W. (2009) · Medical Hypotheses · doi:10.1016/j.mehy.2009.07.045 · Cited by 22 · see citing works
Yang, Y., Landry, M. R., Soyemi, O. O., et al. (2005) · Optics Letters · doi:10.1364/ol.30.002269 · Cited by 22 · see citing works
Whyte, R. K., Nelson, H., Roberts, R. S., & Schmidt, B. K. (2017) · The Journal of Pediatrics · doi:10.1016/j.jpeds.2016.11.076 · Cited by 18 · see citing works
Soyemi, O. O., Landry, M. R., Yang, Y., Idwasi, P. O., & Soller, B. R. (2005) · Applied Spectroscopy · doi:10.1366/0003702053085151 · Cited by 16 · see citing works
Racial bias in pulse oximetry: More statistical detail may help tackle the problem
Philip, K. E. J., Tidswell, R., & McFadyen, C. (2021) · BMJ · doi:10.1136/bmj.n298 · Cited by 16 · see citing works
Legal issues in neonatal-perinatal medicine
Fanaroff, J. M., & Turbow, R. (2011) · Elsevier eBooks · doi:10.1016/b978-0-323-06545-0.00013-3 · Cited by 15 · see citing works
Continuous noninvasive monitoring in the neonatal ICU
Sahni, R. (2017) · Current Opinion in Pediatrics · doi:10.1097/mop.0000000000000459 · Cited by 13 · see citing works
Whitehead, H. V., McPherson, C. C., Vesoulis, Z. A., et al. (2020) · The Journal of Pediatrics · doi:10.1016/j.jpeds.2020.04.043 · Cited by 11 · see citing works
Self-citationNotes on the apparent discordance of pulse oximetry and multi‐wavelength haemoglobin photometry
Nijland, R., Jongsma, H. W., NlJHUIS, J. G., et al. (1995) · Acta Anaesthesiologica Scandinavica · doi:10.1111/j.1399-6576.1995.tb04330.x · Cited by 8 · see citing works
Flagged first, then by citations
Research works printed but not linked: 1
- [32]Montagna W, Prota G, Kenney JA. Jr Black Skin: Structure and Function. Elsevier Science: Saint Louis, 2014. http://qut.eblib.com.au/patron/FullRecord.aspx?p=1190974 (accessed 5 Feb 2021).
Cited by
Sorted by citations
Shi, C., Goodall, M., Dumville, J., Hill, J., Norman, G., Hamer, O., Clegg, A., Watkins, C. L., Georgiou, G., Hodkinson, A., et al. (2022) · doi:10.1101/2022.02.16.22271062 · Cited by 158 · see citing works
Valbuena, V. S. M., Seelye, S., Sjoding, M. W., Valley, T. S., Dickson, R. P., Gay, S. E., Claar, D., Prescott, H. C., & Iwashyna, T. J. (2022) · BMJ · doi:10.1136/bmj-2021-069775 · Cited by 127 · see citing works
Cabanas, A. M., Fuentes-Guajardo, M., Latorre, K., León, D., & Martín-Escudero, P. (2022) · Sensors · doi:10.3390/s22093402 · Cited by 124 · see citing works
Singh, S., Bennett, M. R., Chen, C., Shin, S., Ghanbari, H., & Nelson, B. W. (2024) · Journal of Medical Internet Research · doi:10.2196/62769 · Cited by 36 · see citing works
“The pooled A rms across different skin pigmentation groups was 3.6%, 3.96%, 4.71%, and 4.15% for combined, light, medium, and dark skin pigmentation, respectively (Table 4 and Figures 2-4 [8-11,17,42-51,54-56,58,59]).”
Influential
- Authors
- Vesoulis, Z., Tims, A., Lodhi, H., Lalos, N., & Whitehead, H.
- Affiliations
- Washington University in St. Louis (US)
- Corresponding author
- Vesoulis, Zachary
- Venue
- Journal of Perinatology
- Published
- 2021-10-12
- Volume
- 42
- Issue
- 1
- Pages
- 79-85
- ISSN
- 0743-8346 (ISSN-L)
- 1476-5543
- PMC
- PMC8508473
- OpenAlex
- W3205068012
- Cited by
- 120
- References
- 65
- Citations by year
- 2026: 10 · 2025: 23 · 2024: 24 · 2023: 25 · 2022: 37
- FWCI
- 6.53
- Type
- journal article
- Language
- en
- Open access
- green
- www.ncbi.nlm.nih.gov
- Licence
- Locations
- Journal of Perinatology (publishedVersion)
- PubMed Central (publishedVersion)
- PubMed (publishedVersion)
- Funders
- U.S. Department of Health & Human Services | NIH | National Institute of Neurological Disorders and Stroke (K23 NS111086)
- Topics
- Physical Sciences › Engineering › Biomedical Engineering › Non-Invasive Vital Sign Monitoring
- Health Sciences › Medicine › Pulmonary and Respiratory Medicine › Neonatal Respiratory Health Research
- Health Sciences › Medicine › Pediatrics, Perinatology and Child Health › Neonatal Health and Biochemistry
- Keywords
- pulse oximetry, racial disparities, preterm infants, oxygen saturation, hypoxemia detection, Black infants, measurement accuracy, neonatal monitoring
- MeSH terms
- Adult, Hypoxia, Blood Gas Analysis, Humans, Infant, Newborn, Infant, Premature, Oximetry, Oxygen
About these checks
Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
Statistics and arithmetic are recomputed, not judged.
Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.
What counts as a claim ›How we measure confidence ›How we check this ›
Are you an author, or do you see a problem with this page? Request a review
