Reference: Brennan L et al. Time to change the reference ranges of children’s physiological observations in emergency care? A prospective study. J Paediatr Child Health. March 2023
Date: July 12th, 2023
Guest Skeptic: Dr. Vicki Currie is a paediatric emergency medicine registrar in the West Midlands in the United Kingdom. She is also a member of the Don’t’ Forget the Bubbles team where she serves as the editor for the monthly research round up, Bubble WRAP.
Dr, Vicki Currie
Case: A 5-year-old boy presents to the emergency department (ED) with his parents for fever and fatigue. He has had three days of high fevers at home. His parents report that he has also had a decreased appetite and does not seem interested in drinking liquids. He is usually a happy, active boy but has been very tired over the past day and the parents are having increasing difficulty getting him to wake up. When his vital signs are taken, he is noted to have a temperature of 40°C, a heart rate (HR) of 142 beats per minute (bpm), respiratory rate (RR) of 32 breaths per minute, and blood pressure of 98/60 mmHg. His capillary refill time is three seconds. His parents look at the monitor and ask you, “Is that heart rate normal for him? It seems awfully high. We have been reading online about something called sepsis that can be deadly. Does he have sepsis?”
Background: We have looked at pediatric vital signs on the SGEM back in 2014 with PedEM superhero Dr. Anthony Crocco (SGEM#98). That episode reviewed the 2011 Fleming et al systematic review for the normal ranges of HR and RR in children from birth to 18 years of age. The publication provided useful graphs for clinicians on what is normal.
Vital signs can be an important objective measurement while assessing a patient. They are often incorporated into many early warning systems, risk-stratification systems, and treatment protocols. Abnormal vital signs may be indicators of potential decompensation. Specifically, heart rate and respiratory rates are used in early attempts to detect sepsis.
Children’s vital signs can differ based on age. However, there remains variation regarding what the “normal” ranges of vital signs can be for pediatric patients. Vital sign ranges from common guidelines such as Pediatric Advanced Life Support (PALS) [1] or Advanced Pediatric Life Support (APLS) [2] can differ.
Clinical Question: How does a derived distribution of heart and respiratory rates for children compare to APLS and other national guidance?
Reference: Brennan L, Heal C, Brown S, Roland D, Rowland AG. Time to change the reference ranges of children’s physiological observations in emergency care? A prospective study. J Paediatr Child Health. March 2023
Population: Children 0-16 years recruited consecutively from October 2017 to September 2020 from three emergency departments and one urgent care centre in England- serving populations with significant inequalities in health and life expectancty.
Excluded: none (although impossible values were excluded- Impossible’ values were HR below 50, and RR below 9 or above 90. This did equate to a significant number of records (>11,000 HR and >10,000 RR)
Intervention: Anonymized data for patients’ heart rates and respiratory rates
Comparison: Reference standards in Advanced Paediatric Life Support (APLS)
Outcome: The authors had three aims with their study
Comparison of the distribution of heart and respiratory rates from study to APLS ranges
Proportion of patients from this study that would meet “severe” cut-off threshold compared to guidelines from the UK Sepsis Trust [3] and National Institute for Health and Care Excellence (NICE) [4]
Comparison of distribution of heart and respiratory rates from study to previously published, large data sets [5-7].
Authors’ Conclusions: This study’s data set suggests normal heart rate ranges proposed by the APLS and others is too low and therefore “abnormal” measure...
The Skeptics Guide to Emergency Medicine