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. 2026 Jan 1;144(1):134-142.
doi: 10.1097/ALN.0000000000005738. Epub 2025 Aug 29.

Near-infrared Spectroscopy and Skin Tone in Children: A Prospective Cohort Study

Joseph R Starnes  1 , Wendi Welch  1 , Christopher Henderson  1 , Stephen Hudson  1 , Briana McVean  1 , Scott Risney  2 , George T Nicholson  1 , Thomas P Doyle  1 , Dana Janssen  1 , Bevan P Londergan  3 , David A Parra  1 , James C Slaughter  4 , Muktar H Aliyu  5 , John A Graves  6 , Jonathan H Soslow  1
Affiliations

Near-infrared Spectroscopy and Skin Tone in Children: A Prospective Cohort Study

Joseph R Starnes et al. Anesthesiology. .

Abstract

Background: Retrospective studies suggest that pulse oximetry overestimates saturation in children from races that may be associated with darker skin tone. Near-infrared spectroscopy (NIRS) relies on similar optical technology, but less is known about the effect of skin tone on NIRS. This study aimed to quantify the effect of skin tone on NIRS performance.

Methods: Consecutive patients under 21 yr old undergoing cardiac catheterization were enrolled (N = 110). Skin tone was measured using spectrophotometry. Regional oxygen saturation was recorded from a Medtronic (USA) INVOS 5100C NIRS device placed on the forehead and was compared to the mixed venous saturation. Multivariable linear regressions were used to determine the effect of skin tone measured by individual typology angle (ITA).

Results: Mean bias was larger for patients with darker skin in ITA categories 5 and 6 at -12.8% compared to ITA categories 3 and 4 at -2.5% with a difference of 10.3% (95% CI, 4.4 to 16.3; P < 0.001) and ITA categories 1 and 2 at 0.3% with a difference of 13.1% (95% CI, 7.5 to 18.7; P < 0.001). ITA was associated with NIRS bias in multivariable regression analysis (coefficient, 0.173; P < 0.001).

Conclusions: Darker skin tone is associated with worse NIRS performance and lower NIRS values compared to mixed venous saturation for the INVOS 5100C system. This may lead to differences in care and contribute to inequities in outcomes. Better validation guidelines are needed to ensure equity in performance across varying skin tones.

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Conflict of interest statement

An INVOS 5100C NIRS device was provided by Medtronic (Minneapolis, Minnesota) for the performance of this study. Medtronic had no role in the collection, analysis, or interpretation of the data. They further had no role in the writing of the report or the decision to submit for publication. Dr. Soslow also reports consulting for Capricor (San Diego, California) and Sarepta (Cambridge, Massachusetts) regarding Duchenne muscular dystrophy therapeutics and teaching for NS Pharma (Paramus, New Jersey). The other authors declare no competing interests.

Figures

Fig. 1.
Fig. 1.
Bland–Altman plots. (A) Near-infrared spectroscopy (NIRS) compared to mixed venous oxygen saturation (Svo2) with a mean difference of −2.7% and a 95% limit of agreement of (−21.1, 15.8). (B) NIRS compared to the weighted average of Svo2 and arterial oxygen saturation (Sao2) with a mean difference −8.9% and a 95% limit of agreement of (−26.7, 8.9).
Fig. 2.
Fig. 2.
Predicted error by individual typology angle (ITA). The panels show profile plots of multivariable linear regressions for near-infrared spectroscopy (NIRS) error based on ITA when NIRS was compared to mixed venous oxygen saturation (Svo2; A) and the weighted average of Svo2 and arterial oxygen saturation (Sao2; B). ITA was significantly associated with error using both comparisons. Regressions are adjusted for mixed venous saturation, pH, heart rate, mean arterial pressure, vasopressor use, age, temperature, and hemoglobin level.
See this image and copyright information in PMC

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