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Continuing Medical Education Article

Analysis of the evidence for the lower limit of systolic and mean
arterial pressure in children
Ikram U. Haque, MD, FAAP; Arno L. Zaritsky, MD, FAAP, FCCM

LEARNING OBJECTIVES
On completion of this article, the reader should be able to:
1. Identify key factors that contribute to determining the optimal blood pressure goals for resuscitation of critically ill children.
2. Select appropriate blood pressure targets in critically ill children.
3. Recall the relationship between systolic, diastolic, and mean arterial blood pressure.
Both authors have disclosed that they have no financial relationships with or interests in any commercial companies
pertaining to this educational activity.
Lippincott CME Institute, Inc., has identified and resolved all faculty conflicts of interest regarding this educational activity.
Visit the Pediatric Critical Care Medicine Web site (www.pccmjournal.org) for information on obtaining continuing medical
education credit.

Objective: Systolic blood pressure (SBP) and mean arterial pres- lower than our calculated values in adolescents. Clinical formulas
sure (MAP) are essential evaluation elements in ill children, but there for calculation of SBP and MAP (mm Hg) in normal children are as
is wide variation among different sources defining systolic hypoten- follows: SBP (5th percentile at 50th height percentile) ⴝ 2 ⴛ age
sion in children, and there are no normal reference values for MAP. in years ⴙ 65, MAP (5th percentile at 50th height percentile) ⴝ
Our goal was to calculate the 5th percentile SBP and MAP values in 1.5 ⴛ age in years ⴙ 40, and MAP (50th percentile at 50th height
children from recently updated data published by the task force percentile) ⴝ 1.5 ⴛ age in years ⴙ 55.
working group of the National High Blood Pressure Education Pro- Conclusion: We developed new estimates for values of 5th
gram and compare these values with the lowest limit of acceptable percentile SBP and created a table of normal MAP values for
SBP and MAP defined by different sources. reference. SBP is significantly affected by height, which has not
Design: Mathematical analysis of clinical database. been considered previously. Although the estimated lower limits
Methods: The 50th and 95th percentile SBP values from task of SBP are lower than currently used to define hypotension, these
force data were used to derive the 5th percentile value for children values are derived from normal healthy children and are likely not
from 1 to 17 yrs of age stratified by height percentiles. MAP values appropriate for critically ill children. Our data suggest that the
were calculated using a standard mathematical formula. Calculated current values for hypotension are not evidence-based and may
SBP values were compared with systolic hypotension definitions need to be adjusted for patient height and, most important, for
from other sources. Linear regression analysis was applied to create clinical condition. Specifically, we suggest that the definition of
simple formulas to estimate 5th percentile SBP and 5th and 50th hypotension derived from normal children should not be used to
percentile MAP for different age groups at the 50th height percentile. define the SBP goal; a higher target SBP is likely appropriate in
Results: A 9 –21% range in both SBP and MAP values was many critically ill and injured children. Further studies are needed
noted for different height percentiles in the same age groups. The to evaluate the appropriate threshold values of SBP for determin-
5th percentile SBP values used to define hypotension by different ing hypotension. (Pediatr Crit Care Med 2007; 8:138 –144)
sources are higher than our calculated values in children but are KEY WORDS: blood pressure; hypotension; infant; child

M onitoring blood pressure in diatric emergency department, and in- hypotension is associated with an in-
critically ill or injured chil- tensive care unit (1–5). Studies in adults creased risk of mortality (7–10). The
dren is considered one of and children with trauma showed that depth and duration of hypotension appear
the mainstays for patient systolic blood pressure (SBP) is a predic- to have a direct relationship with adverse
evaluation in the prehospital setting, pe- tor of mortality (6) and that prehospital hospital outcome in emergency depart-
ment patients with nontraumatic shock
(11). Moreover, hypotension is used as a
Assistant Professor (IUH), Professor and Chief Copyright © 2007 by the Society of Critical Care criterion for diagnosis of “decompen-
(ALZ), Division of Pediatric Critical Care Medicine, De- Medicine and the World Federation of Pediatric Inten- sated” shock along with other features of
partment of Pediatrics, University of Florida College of sive and Critical Care Societies poor perfusion in pediatric patients (1, 3).
Medicine, Gainesville, FL. DOI: 10.1097/01.PCC.0000257039.32593.DC Most published guidelines define hypo-

138 Pediatr Crit Care Med 2007 Vol. 8, No. 2


tension in children as an SBP below the which include normalization of MAP to MATERIALS AND METHODS
5th percentile for age. Table 1 is a sum- age-appropriate values in pediatric shock
mary of SBP values as used by the Pedi- states (1, 3, 21–23). Unfortunately, there is The updated blood pressure report is based
atric Advanced Life Support (PALS) little objective evidence defining the target largely on data collected by the National Cen-
course, Brain Trauma Foundation (BTF), ter for Health Statistics with ⬎32,000 boys
values of MAP in pediatric patients. Fur-
and ⬎31,000 girls including new data from
and International Pediatric Sepsis Con- thermore, no age-related MAP nomogram
the 1999 –2000 National Health and Nutrition
sensus Conference to define hypotension in children is available for clinicians to use Examination Survey. The blood pressures re-
in children. These guidelines for hypo- as a reference. Neonatal studies have col- ported by the task force were obtained by
tension are reportedly derived from the lected data on the normal values of blood auscultatory method in normal healthy chil-
reports of the task force on blood pres- pressure in very low birth weight infants dren. The revised blood pressure tables now
sure control in normal healthy children (24 –26), but there are no pediatric studies include the 50th, 90th, 95th, and 99th percen-
(12, 13). Although age-related “norms” of of MAP from children in the pediatric in- tiles by gender, age, and height. The values for
blood pressure are published in most of tensive care unit. When mathematical in- 50th percentile and 95th percentile of SBP and
the relevant pediatric emergency and tegration of invasive arterial pressure mea- diastolic blood pressure were extracted from
critical care training manuals and text- surements to calculate the MAP is not the task force data for all age groups across the
books, the evidence for these norms is available, MAP is typically calculated by us- range of height percentiles into tables for both
usually not referenced and the publica- ing the following formula, which assumes boys and girls (30). We used simple mathemat-
tions do not report the confidence inter- that one third of the cardiac cycle is spent ical calculations to derive the 5th percentile
vals for normal blood pressure or adjust- in systole (27–29): values of SBP from these data, assuming that
ments of these norms for gender or for the data in this large database are normally
height and weight of the child within an distributed so that the difference in pressure
MAP ⫽ diastolic pressure between the 95th and 50th percentile should
age group. Variation in the age-based
range of blood pressure was observed in ⫹ ([systolic pressure be the same as the difference between the 5th
the recently published international con- percentile and 50th percentile. Tables for val-
sensus conference definitions of sepsis ⫺ diastolic pressure]/3) [1] ues of the 5th percentile SBP for different
and organ dysfunction in children, which ages, genders, and height percentiles were
The aim of this study was to use a generated. We then compared calculated val-
included a table of the lower limits of
large published database of blood pres- ues of SBP with currently used guidelines for
acceptable SBP (14). These guidelines re-
sures in children to estimate the lower defining hypotension from different sources.
portedly were based on a review of pub-
limits of systolic pressure and define nor- The published data and our calculated val-
lished studies but appear to overestimate ues of SBP and diastolic pressure at various
the lower limits of SBP in different aged mal mean arterial pressures using the
percentiles of height for a given age were then
children, as shown in Table 1. preceding equation and to compare these
used to estimate the MAPs for age, gender, and
Hemodynamic treatment of shock is estimates with those that are currently
height percentile using the previously stated
aimed at maintaining oxygen delivery being used. To achieve our aim, we used formula. We then used linear regression to
above a critical threshold and increasing data from the working group of the Na- determine the line of best fit and from that
mean arterial pressure (MAP) to a level tional High Blood Pressure Education regression created simple mathematical for-
that allows appropriate distribution of Programs, which recently published up- mulas for clinicians to approximate values of
cardiac output for adequate tissue perfu- dated guidelines on the diagnosis, evalu- the 5th percentile SBP and 5th and 50th per-
sion (15). In adults, a MAP range from 60 ation, and treatment of high blood pres- centile for MAP at the 50th height percentile
to 90 mm Hg has been used as the desired sure in children and adolescents (30). We for children 1–17 yrs of age. We also calculated
target (16 –19) for therapeutic end points analyzed the data from this report using the effect of height on the range of SBP values
such as improved urine output and cre- standard mathematical models to calcu- and derived simple estimates to adjust the SBP
atinine clearance (20). In children, sev- late the 5th percentile values of SBP and according to the height percentile.
eral sources recommend early aggressive diastolic blood pressure for the entire pe-
restoration of hemodynamic end points, diatric population. RESULTS

Table 1. Definition of hypotension in children by different sources The demographic information on the
source of blood pressure data of the pop-
Hypotension Guidelines, mm Hg ulation was described in detail in the
original report (30). Table 2 shows the 5th
Pediatric Advanced Life Brain Trauma International Pediatric Sepsis percentile values of SBP from age 1–18
Age Group Support Foundationa Consensus Conferenceb yrs for males and females; the table also
details the range of SBP for each age
0 days–1 wk ⬍60 ⬍65 ⬍59
1 week–1 mo ⬍60 ⬍65 ⬍79 group ranging from the 5th percentile to
1 mo–1 yr ⬍70 ⬍65 ⬍75 95th percentile for height. As seen in this
⬎1–5 yrs 70 ⫹ 2 ⫻ yrs ⬍70–75 ⬍74 table, the SBP in the same age group
6–12 yrs 70 ⫹ 2 ⫻ yrs (up to 10 yrs) ⬍80–90 ⬍83 varies by approximately 8 –9 mm Hg be-
⬍90 (⬎10 yrs)
tween the 5th and 95th height percentile
13–18 yrs ⬍90 ⬍90 ⬍90
in males and by approximately 6 –7 mm
a
Brain Trauma Foundation last accessed October 14, 2005 (http://www2.braintrauma.org/ Hg in females. Relative to the mean SBP,
guidelines/downloads/btf_guidelines_prehospital.pdf); b corrected values, letter to the editor, Gold- the magnitude of the difference between
stein et al. Pediatr Crit Care Med 2005; 6:500 –501. the 5th and 95th height percentile com-

Pediatr Crit Care Med 2007 Vol. 8, No. 2 139


Table 2. Calculated 5th percentile systolic blood pressure (mm Hg) according to height percentiles olescents exceed the 90 mm Hg threshold
among boys (M) and girls (F) 1–18 yrs old for lower limit of acceptable blood pres-
sure recommended in the PALS and Ad-
Fifth Percentile Systolic Blood Pressure, Percentile for Height
vanced Cardiac Life Support courses for
5th 25th 50th 75th 95th adolescents.

Age, Yrs M F M F M F M F M F
DISCUSSION
1 62 66 65 68 67 68 70 71 72 73
2 67 68 70 70 70 71 72 71 74 73 The early detection and rapid treat-
3 68 68 71 71 73 71 76 74 77 76 ment of hypotension are important in
4 70 71 73 73 75 74 78 74 79 76
the management of critically ill and in-
5 72 71 76 74 78 76 78 77 80 79
6 73 74 76 76 78 77 81 79 83 81 jured children. Moreover, MAP is often
7 74 76 77 78 79 79 81 79 83 82 used as a therapeutic end point in shock
8 77 78 80 78 82 81 82 82 84 84 management. Thus, it is important to
9 77 78 80 81 82 83 85 84 87 86 define the normal ranges for both vari-
10 79 80 83 83 85 85 85 86 89 88
11 81 82 85 85 87 85 87 88 89 90 ables in children. These normal values
12 83 85 86 87 89 87 91 90 93 92 represent a starting point for thinking
13 87 87 88 89 90 90 92 92 94 92 about the desired blood pressure target,
14 88 89 91 89 94 92 96 93 98 95 but the desired target blood pressure in
15 92 90 95 92 95 93 97 93 99 95
16 93 91 96 93 98 93 101 96 103 98 a critically ill or injured child is likely
17 97 91 98 93 100 93 102 96 104 98 higher than these lower limits of nor-
mal blood pressure obtained in healthy
children.
pared with the 50th height percentile and were chosen because they are easier Although not evidence based, hypo-
SBP by age was 7–14.9% in boys and to recall. tension is typically defined as an SBP
5.4 –11.1% in females. This variation is less than the 5th percentile for age.
seen graphically in Figure 1. SBP (5th percentile at 50th height Since it is often difficult to recall blood
The calculated values for MAP at the pressure data listed in tables by age,
percentile) ⫽ 2 ⫻ age in years ⫹ 65 various formulas have been used to es-
5th, 50th, and 95th percentiles stratified
by different height percentiles in the [2] timate the lower limit of acceptable
same age group are shown in Table 3. A blood pressure. For example, the for-
difference of approximately 5– 6 mm Hg SBP (50th percentile at 50th height mula used in PALS training materials
is noted between 5th and 95th height (1) states that the lower limit of accept-
percentile) ⫽ 2 ⫻ age in years ⫹ 85 able SBP is 70 ⫹ 2 ⫻ (age in years) for
percentiles for the same age group in
both males and females. This results in a [3] children from 1 to 10 yrs of age. For
range of MAP across different heights of children ⬍1 yr, the lowest acceptable
8 –13% in girls and 9 –21% in boys. There MAP (5th percentile at 50th height SBP is 60 mm Hg up to 1 month and 70
is wide variation, however, in the normal mm Hg from 1 month to 1 yr. For
percentile) ⫽ 1.5 ⫻ age in years children ⬎10 yrs of age, the lowest ac-
MAP values across the 5th and 95th per-
centiles for a given height. ⫹ 40 [4] ceptable SBP is 90 mm Hg; the latter is
Linear regression was applied to the consistent with Advanced Cardiac Life
50th height percentile group for the 5th MAP (50th percentile at 50th height Support guidelines for defining hypo-
and 50th percentile values of SBP and the tension in adults (31). A review of dif-
percentile) ⫽ 1.5 ⫻ age in years ferent sources revealed substantial vari-
5th and 50th percentile MAP (data not
shown). Simplified formulas for estimat- ⫹ 55 [5] ation in their definition of systolic
ing the 5th percentile SBP and the 5th hypotension, and current sources do
and 50th percentile MAP for 50th percen- The 5th percentile SBPs are plotted as not consider the variation in blood
tile of height were derived from these shown in Figure 1 for both males and pressure due to height differences
values, as shown next. A simple calcula- females along with the PALS, Brain within an age group. Analysis of our
tion can be used to estimate 5th percen- Trauma Foundation, and International derived data from the updated blood
tile SBP adjusted for height percentile for Pediatric Sepsis Consensus Conference pressure data from the task force report
each quartile above or below 50th height definitions and our estimated formulas does not agree with any of the recom-
percentile. Our calculations suggest that for SBP determined from regression anal- mended threshold blood pressures to de-
for males ⫾2 mm Hg for each height ysis. The graph shows that systolic blood fine hypotension, making it difficult for the
quartile and for females ⫾1.5 mm Hg for pressure limits defined by both PALS and clinician to know which source to use and
each quartile of height can approximate Brain Trauma Foundation are high com- remember. Furthermore, it is interesting
the 25th to 75th percentile SBP values. pared with our calculated values, and the to note that the threshold blood pressure
The line of best fit for MAP was exponen- PALS limit often exceeds the 5th percen- values used in the Paediatric Logistic Or-
tial, but the linear equations produce es- tile SBP even in children at the 95th gan Dysfunction score are much higher
timates that are within the range of val- percentile of height. Moreover, the graph than any of the current threshold blood
ues across the range of height percentiles illustrates that most normal healthy ad- pressure values that define hypotension

140 Pediatr Crit Care Med 2007 Vol. 8, No. 2


Figure 1. Fifth percentile systolic blood pressure (BP) according to height (HT) percentiles plotted against Pediatric Advanced Life Support (PALS), Brain
Trauma Foundation (Brain Trauma), and International Pediatric Sepsis Consensus Conference (Int Ped Sepsis) hypotension guidelines, and our new
estimates based on linear regression R2 for boys ⫽ .99 (top) and for girls ⫽ .98 (bottom). Gray lines and the shaded area indicate the calculated values.

Pediatr Crit Care Med 2007 Vol. 8, No. 2 141


Table 3. Calculated mean arterial blood pressure (mm Hg) according to height percentiles among boys (M) and girls (F) 1–18 yrs old

Mean Arterial Blood Pressure for Boys and Girls, Percentile for Height

Percentile 5th 25th 50th 75th 95th


for Blood
Age, Yrs Pressure M F M F M F M F M F

1 5 30 35 33 37 34 37 36 39 37 40
50 49 53 52 54 53 55 54 57 56 58
95 69 71 70 72 72 73 73 74 74 76
2 5 35 39 38 41 39 42 40 42 41 44
50 54 57 56 58 57 59 59 60 60 62
95 73 75 75 76 76 77 77 78 79 80
3 5 39 42 41 44 42 44 44 46 45 47
50 58 60 60 61 61 62 62 64 64 65
95 77 78 78 79 80 80 81 81 82 83
4 5 42 45 43 46 46 47 47 47 48 49
50 61 63 63 64 64 65 66 65 67 67
95 79 80 82 82 83 83 84 84 86 85
5 5 45 46 47 48 49 49 49 50 51 52
50 63 64 66 66 67 67 68 68 69 69
95 82 82 84 83 85 85 87 86 88 87
6 5 47 49 49 50 50 51 52 52 53 54
50 66 66 67 68 69 69 70 69 71 71
95 84 84 86 85 87 86 88 87 90 89
7 5 51 50 50 51 52 52 53 53 54 55
50 67 68 69 69 70 70 72 71 73 72
95 83 85 88 87 89 88 90 89 92 90
8 5 50 52 53 52 54 54 55 55 56 56
50 69 70 71 70 72 71 73 72 75 74
95 87 87 89 88 91 89 92 90 93 91
9 5 51 53 53 54 55 55 56 56 58 57
50 70 71 72 71 73 73 75 74 76 75
95 88 89 91 89 92 90 93 91 94 93
10 5 52 54 55 55 56 56 56 57 59 59
50 71 72 73 73 75 74 75 75 77 76
95 90 90 92 90 93 92 94 93 96 94
11 5 54 55 56 56 57 57 58 59 59 60
50 72 73 74 74 75 75 76 76 78 78
95 91 91 92 92 94 93 95 94 96 95
12 5 54 57 57 58 58 58 60 60 61 61
50 73 75 75 75 77 76 78 78 79 79
95 92 92 94 93 95 94 96 95 98 97
13 5 56 58 57 59 59 60 60 61 61 62
50 75 76 76 77 77 78 79 79 80 80
95 93 94 95 94 96 95 97 97 99 98
14 5 59 60 59 60 61 61 62 62 63 64
50 75 77 78 78 79 79 80 80 82 81
95 91 95 96 96 97 97 99 98 100 99
15 5 58 61 61 61 62 62 63 63 64 64
50 77 78 79 79 80 80 82 81 83 82
95 96 96 98 97 99 98 100 99 102 100
16 5 60 61 62 62 63 63 65 63 66 66
50 79 79 81 80 82 81 83 82 85 84
95 98 96 99 98 101 99 102 100 104 101
17 5 63 61 63 62 65 63 67 65 69 66
50 81 79 83 80 84 81 85 82 87 84
95 100 96 102 98 103 99 104 100 106 101

(32). These empirically derived blood pres- blood pressure in children. Using a re- It is important for clinicians to know
sure values suggest that our current gression model, we developed new simple that there is a fairly large difference on a
thresholds are too low. formulas that give a more accurate ap- percentile basis between the lower limit
Our study analyzed a large database of proximation of 5th percentile SBP for dif- of SBP for a short vs. a tall child. This
blood pressures in children to provide ferent age groups in normal children variation has not previously been reported
objective evidence for the lowest accept- from 1 to 17 yrs of age: or used to adjust the goal for assessment or
able SBP and MAP. Our data show that blood pressure target. We do not know the
the definition of the 5th percentile SBP SBP (5th percentile at 50th height clinical or pathophysiologic significance of
from all the currently used sources is this observation. The estimated SBP for
often higher than the values calculated percentile) ⫽ 2 ⫻ age in years ⫹ 65 25th and 75th percentile height children at
based on the largest available database of [6] a given age can be estimated by adding or

142 Pediatr Crit Care Med 2007 Vol. 8, No. 2


subtracting 2 mm Hg for boys and 1.5 mm CPP ⫽ mean arterial pressure critically ill children than currently used.
Hg for girls from the SBP estimate at the Furthermore, since there is a 5–15%
50th percentile of height. ⫺ intracranial pressure [7] variation in normal SBP from the 5th to
Another important finding was that al- Hence, it is important for clinicians 95th percentile height, the clinician may
though the adult Advanced Cardiac Life caring for critically ill children to know need to consider using a length-based
Support guideline for hypotension uses 90 whether a child’s MAP is appropriate for system for determining the appropriate
mm Hg beyond 12 yrs of age, the 5th per- his or her age. We calculated the values of blood pressure target. Moreover, the cli-
centile values for SBP in normal children MAP tabulated according to height per- nician should recognize that automated
in this age group were ⬎90 mm Hg. The centile for different age groups. The op- blood pressure devices are not reliable
clinical implication of this is not clear ex- timal MAP to achieve adequate tissue per- when distal pulses are weak to absent,
cept that it suggests that clinicians may be fusion pressure in shock is unknown and and other signs of poor perfusion should
accepting a lower SBP than appropriate. likely varies according to the type of be used to define severe shock besides
Moreover, using the lower limit of SBP as shock. As noted, a higher MAP is likely just a low SBP.
the definition of decompensated shock and needed in children with increased intra- Clearly, there is a critical need for
hypotension and especially as the target for cranial pressure. Conversely, in a child studies to validate the appropriate blood
resuscitation may not be appropriate since with cardiogenic shock treated with va- pressure target and to better define hypo-
these definitions are based on data in nor- sodilators, adequate tissue perfusion and tension in critically ill children. To avoid
mal children and do not account for the improved myocardial performance may confusion among pediatric healthcare
stress response that occurs in seriously ill be achieved at a low MAP by maximizing providers, we recommend using a consis-
or injured children. For example, in a re- vasodilator therapy since blood flow is tent definition of hypotension by all pro-
cent study, Dark et al. (33) followed a co- proportional to MAP ⫼ systemic vascular fessional groups developing guidelines
hort of children admitted to the emergency resistance. As a starting estimate of ade- for children. This consistent definition of
department with blunt trauma and found quate perfusion pressure, it may be ap- hypotension, however, should not repre-
that these patients presented with relative propriate to choose the 50th percentile sent the target blood pressure goal. In-
systolic hypertension compared with age- MAP for age and height as a target based stead, we recommend that the target
appropriate SBP as estimated by the guide- on the preceding observations that criti- blood pressure goal should be individu-
lines. They speculated that apparently nor- cally ill children often have elevated ally developed based on adequacy of or-
mal blood pressure in children with blunt blood pressures. Using regression analy- gan perfusion measured by markers of
trauma could represent relative hypoten- sis, we created a formula that approxi- tissue perfusion such as lactate and urine
sion. Another study evaluated the relation- mates the MAP for age in both males and output and considering the etiology of
ship between blood pressures and outcome females: the shock state. For example, epidemio-
after severe traumatic brain injury in pedi- logic studies in trauma patients suggest
atric patients (34). Poor outcome was asso- MAP (5th percentile at 50th height that a higher blood pressure target is
ciated with an SBP less than the age- appropriate, but this has not been tested
adjusted 75th percentile even if the SBP percentile) ⫽ 1.5 ⫻ age in years prospectively. We also calculated normal
was ⱖ90 mm Hg. White et al. (35) reported ⫹ 40 [8] values for MAP to be used as reference
that the odds of survival increased 19-fold values while treating critically ill chil-
in pediatric severe traumatic brain injury MAP (50th percentile at 50th height dren. Further research is needed to iden-
patients with maximum SBP of ⬎135 mm tify appropriate SBP and MAP treatment
Hg, also suggesting that supranormal percentile) ⫽ 1.5 ⫻ age in years goals in populations of critically ill and
blood pressures are associated with im- ⫹ 55 [9] injured children, such as children with
proved outcome in this patient population. traumatic brain injury, to better deter-
These studies highlight that a higher SBP Clinicians should recall that MAP val- mine the optimal therapeutic end point.
target may be particularly important in ues vary across the height percentile
children with traumatic brain injury in within the same age group, and this vari-
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