This document summarizes a systematic review of observational studies that aimed to establish normal ranges of heart rate and respiratory rate in children from birth to 18 years old. The review identified 69 studies with heart rate data for over 143,000 children and respiratory rate data for over 3,800 children. Using non-parametric kernel regression, the researchers created new centile charts for heart rate and respiratory rate in relation to age. Their charts showed a decline in respiratory rate from birth to adolescence, with heart rate peaking at 1 month before decreasing by age 2. Comparison of the new centile charts to existing reference ranges revealed significant disagreement, with published ranges exceeding the new 99th and 1st centiles or crossing the median. The researchers
Improving adult asthma care: testing the case for changeNHS Improvement
This document summarizes projects undertaken by various NHS organizations in England to improve adult asthma care. It provides an overview of common challenges in asthma management and potential solutions tested by different projects. These include standardizing care according to clinical guidelines, validating patient registers, conducting annual patient reviews, supporting self-management, and taking integrated, multidisciplinary approaches. The document highlights emerging principles for successful service improvement, such as understanding the current patient pathway, collecting baseline data, collaborating across disciplines, and involving patients. Case studies from acute trusts, community teams, and clinical commissioning groups provide examples of specific changes tested.
Prophylactic Aminophylline for Prevention of Apnea at Higher-Risk Preterm Neo...amir mohammad Armanian
1. The study assessed the prophylactic effects of aminophylline on apnea in preterm neonates with a gestational age less than 32 weeks and/or birth weight less than 1200g.
2. 52 neonates were randomly assigned to receive either aminophylline (group A) or no aminophylline (group C) for the first 10 days.
3. Primary outcomes like apnea, bradycardia and cyanosis were significantly lower in the aminophylline group compared to the control group. Secondary outcomes like need for CPAP and length of hospital stay were also lower in the aminophylline group.
This study evaluated the effectiveness of low-fractional concentration continuous positive airway pressure (CPAP) in the prehospital setting. 340 patients with respiratory distress were treated with CPAP providing a fixed oxygen concentration of 28-30%. Improvements were seen in respiratory rate and oxygen saturation levels. CPAP was discontinued for 16.5% of patients, mostly due to anxiety or requiring intubation. 71.5% of patients' conditions were improved with CPAP treatment based on paramedic assessment. The results suggest CPAP with a low fixed oxygen concentration is effective for commonly encountered respiratory emergencies in the prehospital setting.
Assessment of Effects of Traditional Exercise on Galvanic Skin Response, Puls...BRNSS Publication Hub
This study assessed the effects of traditional pranayama exercise on galvanic skin response (GSR), pulse rate, and blood pressure in 15 prehypertensive patients over 30 days. No significant changes in GSR were seen after 15 days, but significant improvements were seen after 30 days. Pulse rate and blood pressure also significantly improved after 15 and 30 days. The study concluded that regular pranayama practice increases parasympathetic tone, reduces sympathetic tone, and has beneficial effects on GSR, pulse rate, and blood pressure.
Anaesthesia in women and women in anaesthesia - Else Tønnesen - SSAI2017scanFOAM
A talk by Else Tönnesen at the 2017 meeting of the Scandinavian Society of Anaestesiology and Intensive Care Medicine.
All available content from SSAI2017: https://scanfoam.org/ssai2017/
Content delivered in collaboration between scanFOAM, SSAI & SFAI.
EL LAVADO DE MANOS - TIPOS - INDICACIONES - MATERIALES. Prof. Dr. Luis del Ri...LUIS del Rio Diez
TIPOS DE ANESTESICOS LOCALES - USOS - INDICACIONES - CONTRAINDICACIONES -CLASE INTEGRANTE DEL CURSO DE PRACTICAS QUIRURGICAS BASICAS DEL COLEGIO DE MEDICOS DE ROSARIO- CASA DE LA EDUCACION MEDICA - Prof. Dr. Luis del Rio Diez
Cardiac complications in acute ischemic strokeHans Garcia
This study characterized cardiac complications in 200 patients with acute ischemic stroke who were admitted to an urban hospital. The researchers found that:
- 28.5% of patients had systolic dysfunction defined as an ejection fraction less than 50% on echocardiography
- 20.4% had ischemic changes, 10.5% presented with atrial fibrillation, and 13% had troponin elevation on electrocardiograms
- Patients with systolic dysfunction, troponin elevation, atrial fibrillation, or ischemic changes on electrocardiograms had significantly higher in-hospital mortality rates.
The findings suggest that cardiac monitoring strategies may be important for managing some acute ischemic stroke patients.
Indice Predictor de Asma en edad pediátricaYan Giraldo G
This document describes a study that developed two indices to predict the risk of asthma in young children with recurrent wheezing. The researchers used data from the Tucson Children's Respiratory Study to create a stringent index and a loose index based on combinations of wheezing frequency, family history, eczema, allergic rhinitis, eosinophilia, and wheezing apart from colds. Children who met the criteria for the loose index had 2.6 to 5.5 times higher risk of active asthma between ages 6-13. Those who met the stringent index criteria had 4.3 to 9.8 times higher risk. 59% of children with a positive loose index and 76% of those with a positive
Improving adult asthma care: testing the case for changeNHS Improvement
This document summarizes projects undertaken by various NHS organizations in England to improve adult asthma care. It provides an overview of common challenges in asthma management and potential solutions tested by different projects. These include standardizing care according to clinical guidelines, validating patient registers, conducting annual patient reviews, supporting self-management, and taking integrated, multidisciplinary approaches. The document highlights emerging principles for successful service improvement, such as understanding the current patient pathway, collecting baseline data, collaborating across disciplines, and involving patients. Case studies from acute trusts, community teams, and clinical commissioning groups provide examples of specific changes tested.
Prophylactic Aminophylline for Prevention of Apnea at Higher-Risk Preterm Neo...amir mohammad Armanian
1. The study assessed the prophylactic effects of aminophylline on apnea in preterm neonates with a gestational age less than 32 weeks and/or birth weight less than 1200g.
2. 52 neonates were randomly assigned to receive either aminophylline (group A) or no aminophylline (group C) for the first 10 days.
3. Primary outcomes like apnea, bradycardia and cyanosis were significantly lower in the aminophylline group compared to the control group. Secondary outcomes like need for CPAP and length of hospital stay were also lower in the aminophylline group.
This study evaluated the effectiveness of low-fractional concentration continuous positive airway pressure (CPAP) in the prehospital setting. 340 patients with respiratory distress were treated with CPAP providing a fixed oxygen concentration of 28-30%. Improvements were seen in respiratory rate and oxygen saturation levels. CPAP was discontinued for 16.5% of patients, mostly due to anxiety or requiring intubation. 71.5% of patients' conditions were improved with CPAP treatment based on paramedic assessment. The results suggest CPAP with a low fixed oxygen concentration is effective for commonly encountered respiratory emergencies in the prehospital setting.
Assessment of Effects of Traditional Exercise on Galvanic Skin Response, Puls...BRNSS Publication Hub
This study assessed the effects of traditional pranayama exercise on galvanic skin response (GSR), pulse rate, and blood pressure in 15 prehypertensive patients over 30 days. No significant changes in GSR were seen after 15 days, but significant improvements were seen after 30 days. Pulse rate and blood pressure also significantly improved after 15 and 30 days. The study concluded that regular pranayama practice increases parasympathetic tone, reduces sympathetic tone, and has beneficial effects on GSR, pulse rate, and blood pressure.
Anaesthesia in women and women in anaesthesia - Else Tønnesen - SSAI2017scanFOAM
A talk by Else Tönnesen at the 2017 meeting of the Scandinavian Society of Anaestesiology and Intensive Care Medicine.
All available content from SSAI2017: https://scanfoam.org/ssai2017/
Content delivered in collaboration between scanFOAM, SSAI & SFAI.
EL LAVADO DE MANOS - TIPOS - INDICACIONES - MATERIALES. Prof. Dr. Luis del Ri...LUIS del Rio Diez
TIPOS DE ANESTESICOS LOCALES - USOS - INDICACIONES - CONTRAINDICACIONES -CLASE INTEGRANTE DEL CURSO DE PRACTICAS QUIRURGICAS BASICAS DEL COLEGIO DE MEDICOS DE ROSARIO- CASA DE LA EDUCACION MEDICA - Prof. Dr. Luis del Rio Diez
Cardiac complications in acute ischemic strokeHans Garcia
This study characterized cardiac complications in 200 patients with acute ischemic stroke who were admitted to an urban hospital. The researchers found that:
- 28.5% of patients had systolic dysfunction defined as an ejection fraction less than 50% on echocardiography
- 20.4% had ischemic changes, 10.5% presented with atrial fibrillation, and 13% had troponin elevation on electrocardiograms
- Patients with systolic dysfunction, troponin elevation, atrial fibrillation, or ischemic changes on electrocardiograms had significantly higher in-hospital mortality rates.
The findings suggest that cardiac monitoring strategies may be important for managing some acute ischemic stroke patients.
Indice Predictor de Asma en edad pediátricaYan Giraldo G
This document describes a study that developed two indices to predict the risk of asthma in young children with recurrent wheezing. The researchers used data from the Tucson Children's Respiratory Study to create a stringent index and a loose index based on combinations of wheezing frequency, family history, eczema, allergic rhinitis, eosinophilia, and wheezing apart from colds. Children who met the criteria for the loose index had 2.6 to 5.5 times higher risk of active asthma between ages 6-13. Those who met the stringent index criteria had 4.3 to 9.8 times higher risk. 59% of children with a positive loose index and 76% of those with a positive
This study examined the effects of progressive weight gain on the development of atrial fibrillation (AF) in sheep. Sheep were fed a high calorie diet to induce obesity over 8 months while controls maintained normal weight. Cardiac imaging, electrophysiological testing, histology, and molecular analysis were performed at baseline, 4 months, and 8 months. The results showed that increasing weight was associated with larger left atrial size, more atrial fibrosis, inflammation and lipid deposits. Weight gain also reduced conduction velocity, increased conduction heterogeneity and AF inducibility. Molecular markers of fibrosis increased with greater adiposity. Therefore, progressive obesity leads to structural and electrical remodeling in the atria that promotes the development of AF.
This randomized controlled trial studied 998 patients with septic shock to compare mortality outcomes of a lower hemoglobin threshold (7 g/dL) versus a higher threshold (9 g/dL) for red blood cell transfusion. Patients received single unit transfusions when their hemoglobin level fell below the assigned threshold. The lower threshold group received fewer median transfusions (1 unit) than the higher threshold group (4 units). At 90 days, mortality was similar between the groups, with 43.0% of the lower threshold group and 45.0% of the higher threshold group deceased. Rates of ischemic events and life support use were also similar between the groups. The study found that a lower hemoglobin threshold for transfusion in
Prognosis of pulmonary arterial hypertensiongisa_legal
1) The expected survival of patients with pulmonary arterial hypertension (PAH) varies based on the underlying cause, with idiopathic PAH having a median survival of 2.8 years based on historical studies.
2) Medical therapies like epoprostenol have improved survival rates, with studies showing 1, 2, and 3 year survival rates with epoprostenol between 63-87%, compared to 27-52% historically.
3) The prognosis is worse for PAH associated with scleroderma or collagen vascular diseases, with median survival around 1-2 years, while PAH associated with congenital heart disease has a better prognosis, with reported 3 year survival of 77%.
Presentation on utility of ultrasound in the arena of prehospital and retrieval medicine.
I intentionally strayed away from e-FAST & focussed more on the ongoing resuscitation of a medically shocked patient.
Drs. Olson’s and Jackson’s CMC Pediatric X-Ray Mastery: December CasesSean M. Fox
Drs. Olson and Jackson are interested in education and Pediatric Emergency Medicine. Follow along with the EMGuideWire.com team and Drs. Nikki Richardson, Mary Grady, and Michael Gibbs as they post these educational, self-guided radiology slides on Pediatric Emergency Medicine Radiology. This month’s topics include:
- Hemopneumothorax
- COVID Pneumonia
- Metastatic Testicular Cancer
- Tension Pneumothorax
- Acute Chest Syndrome
- Status Asthmaticus
- Severe Anemia
- Pulmonary Infarct and Pulmonary Embolism
2020 state of the art—high-sensitivity troponins in acute coronary syndromesBryanMielesM
This document discusses the evolution of biomarkers for diagnosing acute myocardial infarction (AMI), focusing on high-sensitivity troponin assays. It notes that while biomarkers like liver enzymes, CK, and LDH were initially used, troponin is now considered the gold standard due to its high cardiac specificity. The development of high-sensitivity troponin assays allows for earlier rule-in and rule-out of AMI. However, these assays are also detecting myocardial injury from non-ischemic causes, challenging clinicians. The document reviews new consensus definitions distinguishing acute myocardial injury, ischemia, and infarction to help clinicians interpret troponin results.
Drs. Olson’s and Jackson’s CMC Pediatric X-Ray Mastery: April CasesSean M. Fox
Drs. Olson and Jackson are interested in education and Pediatric Emergency Medicine. Follow along with the EMGuideWire.com team and Drs. Nikki Richardson, Mary Grady, and Michael Gibbs as they post these educational, self-guided radiology slides on Pediatric Emergency Medicine Radiology. This month’s topics include:
• Tension pneumothorax
• MIS-C
• Fungal Pneumonia
• Systemic JIA
• Large Pericardial Effusion
• Post-obstructive Pulmonary Edema
• Normal Thymus
• Pneumonia
Clinical profile of paediatric patients with rheumatic heart disease at moi t...Alexander Decker
This document summarizes a study on the clinical profile of pediatric patients with rheumatic heart disease at Moi Teaching and Referral Hospital in Eldoret, Kenya. The study found that the most common symptoms in new patients were dyspnea, easy fatigability, palpitations, cough and orthopnea. The most common signs were systolic murmurs, thrills and tachycardia. Most new patients presented with severe disease in NYHA class 3 or 4. Mitral regurgitation alone or combined with aortic regurgitation were the most common valve lesions. The results suggest that most new patients have advanced valvular disease and complications due to late presentation, highlighting the need for early detection
Clinical profile of paediatric patients with rheumatic heart disease at moi t...Alexander Decker
This document summarizes a study on the clinical profile of pediatric patients with rheumatic heart disease at Moi Teaching and Referral Hospital in Eldoret, Kenya. The study found that 84 pediatric patients had rheumatic heart disease, with more female patients than male. New patients most commonly presented with dyspnea, easy fatigability, and palpitations. Signs like systolic murmurs and tachycardia were also common in new patients. Most new patients were in NYHA classes 3 and 4, indicating severe valvular disease and late presentation. The study recommends emphasis on early detection and prevention of rheumatic heart disease.
This randomized controlled trial investigated whether providing multiple courses of antenatal corticosteroids every 14 days reduced neonatal morbidity and mortality without negatively impacting fetal growth. 1858 women between 25-32 weeks gestation who remained at risk of preterm birth after an initial corticosteroid course were assigned to receive multiple corticosteroid courses or placebo until 33 weeks or delivery. The trial found no difference in neonatal outcomes between groups. Infants exposed to multiple corticosteroid courses weighed less and had smaller head circumferences at birth, suggesting the treatment negatively impacted fetal growth. The study concludes multiple corticosteroid courses every 14 days is not recommended due to lack of benefit and potential for decreased fetal growth.
This study aimed to establish a complete set of reference ranges for 18 parameters routinely measured during perinatal autopsies in Australia. The study reviewed 1116 autopsy reports from a hospital between 2001-2006. Reference ranges including means, standard deviations, and percentiles were produced for each parameter by gestational age from 12 to 42 weeks. The reference ranges account for the mixed immigrant population in Australia and will be valuable for perinatal pathologists.
The study analyzed 201 preterm neonates treated medically or surgically for a patent ductus arteriosus (PDA). The mean PDA diameter was significantly larger in patients where medical treatment failed compared to those where it succeeded. An index of PDA diameter squared divided by birth weight below 9 mm2/kg correctly predicted successful medical closure in 87.5% of patients, while an index above 9 mm2/kg correctly predicted medication failure in 41.5% of patients. Respiration time was significantly longer before PDA closure in patients where medication failed compared to those where it succeeded, but similar after closure between groups. Larger PDA size and lower birth weight make medical treatment more likely to fail.
Respiratory system disorders and therapyElsa von Licy
This document provides information about a publication on respiratory system disorders and therapy from a new, dynamic viewpoint. It discusses the Louis Bolk Institute, which conducted the research, and its goal of furthering organic and sustainable practices. It also provides publishing details and contact information for the authors and institute. The publication aims to demonstrate how insights from biomedicine can be expanded using a Goethean phenomenological method to provide a more holistic understanding of health, illness, and therapy.
Effetti degli integratori di calcio sul rischio di infarto del miocardio e di...Merqurio
This meta-analysis investigated whether calcium supplements increase the risk of cardiovascular events. It analyzed 15 eligible randomized controlled trials involving over 11,000 participants who took calcium supplements for an average of 4 years. The analysis found a small increased risk of myocardial infarction among those taking calcium supplements compared to placebo, with 143 people experiencing a heart attack in the calcium group versus 111 in the placebo group. There was also a non-significant trend towards increased risks of stroke and cardiovascular death. These modest increases in risk could translate to a significant burden of disease at the population level given widespread calcium supplement use. The results suggest a reassessment of calcium supplements for osteoporosis is warranted.
Effetti degli integratori di calcio sul rischio di infarto del miocardio e di...Merqurio
This meta-analysis found that calcium supplements may modestly increase the risk of cardiovascular events like myocardial infarction. The analysis included 15 randomized controlled trials involving over 11,000 participants. It found that those taking calcium supplements had a 31% higher risk of myocardial infarction compared to placebo based on individual patient data. Trial-level data also showed a 27% higher risk. These modest increases could translate to a significant disease burden in the population given calcium supplements' widespread use. The results suggest reassessing calcium supplements' role in osteoporosis management.
This study evaluated 84 patients diagnosed with hypertrophic pyloric stenosis (HPS) to assess the ability of physicians to detect the condition through clinical examination compared to sonography and barium studies. The olive sign was detected in only 13 patients (15.5%) on clinical examination. Sonography revealed HPS in 71 of 81 patients (87.7%), while barium studies found HPS in 16 of 21 patients (76.2%). Sonography was significantly more accurate at detecting HPS than clinical examination. Due to the difficulty examining crying infants and increased availability of imaging, physicians' skills at detecting the olive sign through physical examination are declining, leading to underutilization of this important diagnostic tool.
El documento discute los cambios fisiológicos durante el embarazo que afectan al sistema cardiovascular y las complicaciones potenciales en mujeres con cardiopatía. Señala que el embarazo aumenta la frecuencia cardíaca, el gasto cardíaco y el volumen sanguíneo, lo que puede sobrecargar el corazón. También analiza los factores de riesgo maternos y fetales y las consideraciones para el tratamiento de la cardiopatía durante el embarazo.
Al nacer, se modifica toda la circulación fetal para adaptarse al medio extrauterino. Se cierra la circulación umbilico-placentaria, así como los cortocircuitos fetales como el foramen oval y el conducto arterioso. Esto fuerza a la sangre a circular a través de los pulmones para su oxigenación, permitiendo la supervivencia del recién nacido una vez cortado el cordón umbilical.
More Related Content
Similar to Valores normales de fc y fr en niños lancet 2011
This study examined the effects of progressive weight gain on the development of atrial fibrillation (AF) in sheep. Sheep were fed a high calorie diet to induce obesity over 8 months while controls maintained normal weight. Cardiac imaging, electrophysiological testing, histology, and molecular analysis were performed at baseline, 4 months, and 8 months. The results showed that increasing weight was associated with larger left atrial size, more atrial fibrosis, inflammation and lipid deposits. Weight gain also reduced conduction velocity, increased conduction heterogeneity and AF inducibility. Molecular markers of fibrosis increased with greater adiposity. Therefore, progressive obesity leads to structural and electrical remodeling in the atria that promotes the development of AF.
This randomized controlled trial studied 998 patients with septic shock to compare mortality outcomes of a lower hemoglobin threshold (7 g/dL) versus a higher threshold (9 g/dL) for red blood cell transfusion. Patients received single unit transfusions when their hemoglobin level fell below the assigned threshold. The lower threshold group received fewer median transfusions (1 unit) than the higher threshold group (4 units). At 90 days, mortality was similar between the groups, with 43.0% of the lower threshold group and 45.0% of the higher threshold group deceased. Rates of ischemic events and life support use were also similar between the groups. The study found that a lower hemoglobin threshold for transfusion in
Prognosis of pulmonary arterial hypertensiongisa_legal
1) The expected survival of patients with pulmonary arterial hypertension (PAH) varies based on the underlying cause, with idiopathic PAH having a median survival of 2.8 years based on historical studies.
2) Medical therapies like epoprostenol have improved survival rates, with studies showing 1, 2, and 3 year survival rates with epoprostenol between 63-87%, compared to 27-52% historically.
3) The prognosis is worse for PAH associated with scleroderma or collagen vascular diseases, with median survival around 1-2 years, while PAH associated with congenital heart disease has a better prognosis, with reported 3 year survival of 77%.
Presentation on utility of ultrasound in the arena of prehospital and retrieval medicine.
I intentionally strayed away from e-FAST & focussed more on the ongoing resuscitation of a medically shocked patient.
Drs. Olson’s and Jackson’s CMC Pediatric X-Ray Mastery: December CasesSean M. Fox
Drs. Olson and Jackson are interested in education and Pediatric Emergency Medicine. Follow along with the EMGuideWire.com team and Drs. Nikki Richardson, Mary Grady, and Michael Gibbs as they post these educational, self-guided radiology slides on Pediatric Emergency Medicine Radiology. This month’s topics include:
- Hemopneumothorax
- COVID Pneumonia
- Metastatic Testicular Cancer
- Tension Pneumothorax
- Acute Chest Syndrome
- Status Asthmaticus
- Severe Anemia
- Pulmonary Infarct and Pulmonary Embolism
2020 state of the art—high-sensitivity troponins in acute coronary syndromesBryanMielesM
This document discusses the evolution of biomarkers for diagnosing acute myocardial infarction (AMI), focusing on high-sensitivity troponin assays. It notes that while biomarkers like liver enzymes, CK, and LDH were initially used, troponin is now considered the gold standard due to its high cardiac specificity. The development of high-sensitivity troponin assays allows for earlier rule-in and rule-out of AMI. However, these assays are also detecting myocardial injury from non-ischemic causes, challenging clinicians. The document reviews new consensus definitions distinguishing acute myocardial injury, ischemia, and infarction to help clinicians interpret troponin results.
Drs. Olson’s and Jackson’s CMC Pediatric X-Ray Mastery: April CasesSean M. Fox
Drs. Olson and Jackson are interested in education and Pediatric Emergency Medicine. Follow along with the EMGuideWire.com team and Drs. Nikki Richardson, Mary Grady, and Michael Gibbs as they post these educational, self-guided radiology slides on Pediatric Emergency Medicine Radiology. This month’s topics include:
• Tension pneumothorax
• MIS-C
• Fungal Pneumonia
• Systemic JIA
• Large Pericardial Effusion
• Post-obstructive Pulmonary Edema
• Normal Thymus
• Pneumonia
Clinical profile of paediatric patients with rheumatic heart disease at moi t...Alexander Decker
This document summarizes a study on the clinical profile of pediatric patients with rheumatic heart disease at Moi Teaching and Referral Hospital in Eldoret, Kenya. The study found that the most common symptoms in new patients were dyspnea, easy fatigability, palpitations, cough and orthopnea. The most common signs were systolic murmurs, thrills and tachycardia. Most new patients presented with severe disease in NYHA class 3 or 4. Mitral regurgitation alone or combined with aortic regurgitation were the most common valve lesions. The results suggest that most new patients have advanced valvular disease and complications due to late presentation, highlighting the need for early detection
Clinical profile of paediatric patients with rheumatic heart disease at moi t...Alexander Decker
This document summarizes a study on the clinical profile of pediatric patients with rheumatic heart disease at Moi Teaching and Referral Hospital in Eldoret, Kenya. The study found that 84 pediatric patients had rheumatic heart disease, with more female patients than male. New patients most commonly presented with dyspnea, easy fatigability, and palpitations. Signs like systolic murmurs and tachycardia were also common in new patients. Most new patients were in NYHA classes 3 and 4, indicating severe valvular disease and late presentation. The study recommends emphasis on early detection and prevention of rheumatic heart disease.
This randomized controlled trial investigated whether providing multiple courses of antenatal corticosteroids every 14 days reduced neonatal morbidity and mortality without negatively impacting fetal growth. 1858 women between 25-32 weeks gestation who remained at risk of preterm birth after an initial corticosteroid course were assigned to receive multiple corticosteroid courses or placebo until 33 weeks or delivery. The trial found no difference in neonatal outcomes between groups. Infants exposed to multiple corticosteroid courses weighed less and had smaller head circumferences at birth, suggesting the treatment negatively impacted fetal growth. The study concludes multiple corticosteroid courses every 14 days is not recommended due to lack of benefit and potential for decreased fetal growth.
This study aimed to establish a complete set of reference ranges for 18 parameters routinely measured during perinatal autopsies in Australia. The study reviewed 1116 autopsy reports from a hospital between 2001-2006. Reference ranges including means, standard deviations, and percentiles were produced for each parameter by gestational age from 12 to 42 weeks. The reference ranges account for the mixed immigrant population in Australia and will be valuable for perinatal pathologists.
The study analyzed 201 preterm neonates treated medically or surgically for a patent ductus arteriosus (PDA). The mean PDA diameter was significantly larger in patients where medical treatment failed compared to those where it succeeded. An index of PDA diameter squared divided by birth weight below 9 mm2/kg correctly predicted successful medical closure in 87.5% of patients, while an index above 9 mm2/kg correctly predicted medication failure in 41.5% of patients. Respiration time was significantly longer before PDA closure in patients where medication failed compared to those where it succeeded, but similar after closure between groups. Larger PDA size and lower birth weight make medical treatment more likely to fail.
Respiratory system disorders and therapyElsa von Licy
This document provides information about a publication on respiratory system disorders and therapy from a new, dynamic viewpoint. It discusses the Louis Bolk Institute, which conducted the research, and its goal of furthering organic and sustainable practices. It also provides publishing details and contact information for the authors and institute. The publication aims to demonstrate how insights from biomedicine can be expanded using a Goethean phenomenological method to provide a more holistic understanding of health, illness, and therapy.
Effetti degli integratori di calcio sul rischio di infarto del miocardio e di...Merqurio
This meta-analysis investigated whether calcium supplements increase the risk of cardiovascular events. It analyzed 15 eligible randomized controlled trials involving over 11,000 participants who took calcium supplements for an average of 4 years. The analysis found a small increased risk of myocardial infarction among those taking calcium supplements compared to placebo, with 143 people experiencing a heart attack in the calcium group versus 111 in the placebo group. There was also a non-significant trend towards increased risks of stroke and cardiovascular death. These modest increases in risk could translate to a significant burden of disease at the population level given widespread calcium supplement use. The results suggest a reassessment of calcium supplements for osteoporosis is warranted.
Effetti degli integratori di calcio sul rischio di infarto del miocardio e di...Merqurio
This meta-analysis found that calcium supplements may modestly increase the risk of cardiovascular events like myocardial infarction. The analysis included 15 randomized controlled trials involving over 11,000 participants. It found that those taking calcium supplements had a 31% higher risk of myocardial infarction compared to placebo based on individual patient data. Trial-level data also showed a 27% higher risk. These modest increases could translate to a significant disease burden in the population given calcium supplements' widespread use. The results suggest reassessing calcium supplements' role in osteoporosis management.
This study evaluated 84 patients diagnosed with hypertrophic pyloric stenosis (HPS) to assess the ability of physicians to detect the condition through clinical examination compared to sonography and barium studies. The olive sign was detected in only 13 patients (15.5%) on clinical examination. Sonography revealed HPS in 71 of 81 patients (87.7%), while barium studies found HPS in 16 of 21 patients (76.2%). Sonography was significantly more accurate at detecting HPS than clinical examination. Due to the difficulty examining crying infants and increased availability of imaging, physicians' skills at detecting the olive sign through physical examination are declining, leading to underutilization of this important diagnostic tool.
Similar to Valores normales de fc y fr en niños lancet 2011 (20)
El documento discute los cambios fisiológicos durante el embarazo que afectan al sistema cardiovascular y las complicaciones potenciales en mujeres con cardiopatía. Señala que el embarazo aumenta la frecuencia cardíaca, el gasto cardíaco y el volumen sanguíneo, lo que puede sobrecargar el corazón. También analiza los factores de riesgo maternos y fetales y las consideraciones para el tratamiento de la cardiopatía durante el embarazo.
Al nacer, se modifica toda la circulación fetal para adaptarse al medio extrauterino. Se cierra la circulación umbilico-placentaria, así como los cortocircuitos fetales como el foramen oval y el conducto arterioso. Esto fuerza a la sangre a circular a través de los pulmones para su oxigenación, permitiendo la supervivencia del recién nacido una vez cortado el cordón umbilical.
Este documento resume el servicio de cardiología congénita para adultos en un hospital mexicano. Explica que el 85% de los niños nacidos con cardiopatía congénita ahora llegan a la edad adulta. Describe las cardiopatías más comunes en adultos, los motivos más frecuentes de consulta, y las opciones de tratamiento quirúrgico e intervencionista. Resalta la necesidad de un enfoque multidisciplinario para brindar la mejor atención a esta población en crecimiento.
Este documento describe nuevos métodos como el ecocardiograma 3D y el speckle tracking para evaluar la función del ventrículo derecho en pacientes con cardiopatías congénitas. Estos métodos ofrecen una evaluación cuantitativa más precisa de la función ventricular derecha en comparación con métodos tradicionales cualitativos. El speckle tracking en particular puede medir parámetros como el strain y strain rate que proporcionan información adicional sobre el remodelamiento y la función miocárdica. Estos nuevos enfoques mejoran el diagnóstico y estrat
Generalidades de Cardiopatías CongénitasLucelli Yanez
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Las cardiopatías congénitas afectan a aproximadamente 8 de cada 1,000 embarazos y 40,000 casos nuevos anualmente, siendo la causa principal de mortalidad infantil. Aunque la mayoría de los pacientes requieren atención médica urgente en el primer año de vida, alrededor del 85% lograrán llegar a la edad adulta gracias a los avances en el tratamiento como medicamentos, cateterismo e cirugía. Las cardiopatías congénitas pueden clasificarse en dos grupos principales y presentan una amplia gama de sí
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Valores normales de fc y fr en niños lancet 2011
1. Articles
Normal ranges of heart rate and respiratory rate in children
from birth to 18 years of age: a systematic review of
observational studies
Susannah Fleming, Matthew Thompson, Richard Stevens, Carl Heneghan, Annette Plüddemann, Ian Maconochie, Lionel Tarassenko, David Mant
Summary
Background Although heart rate and respiratory rate in children are measured routinely in acute settings, current Lancet 2011; 377: 1011–18
reference ranges are not based on evidence. We aimed to derive new centile charts for these vital signs and to Published Online
compare these centiles with existing international ranges. March 15, 2011
DOI:10.1016/S0140-
6736(10)62226-X
Methods We searched Medline, Embase, CINAHL, and reference lists for studies that reported heart rate or
See Comment page 974
respiratory rate of healthy children between birth and 18 years of age. We used non-parametric kernel regression to
Oxford University, Department
create centile charts for heart rate and respiratory rate in relation to age. We compared existing reference ranges with of Primary Health Care,
those derived from our centile charts. Rosemary Rue Building, Old
Road Campus, Headington,
Findings We identified 69 studies with heart rate data for 143 346 children and respiratory rate data for 3881 children. Oxford, UK (S Fleming DPhil,
M Thompson DPhil,
Our centile charts show decline in respiratory rate from birth to early adolescence, with the steepest fall apparent R Stevens PhD,
in infants under 2 years of age; decreasing from a median of 44 breaths per min at birth to 26 breaths per min at C Heneghan DPhil,
2 years. Heart rate shows a small peak at age 1 month. Median heart rate increases from 127 beats per min at birth A Plüddemann PhD,
D Mant FMedSci); Department
to a maximum of 145 beats per min at about 1 month, before decreasing to 113 beats per min by 2 years of age.
of Family Medicine, Oregon
Comparison of our centile charts with existing published reference ranges for heart rate and respiratory rate show Health and Sciences University,
striking disagreement, with limits from published ranges frequently exceeding the 99th and 1st centiles, or Portland, OR, USA
crossing the median. (M Thompson); Accident and
Emergency, St Mary’s Hospital,
Praed St, London, UK
Interpretation Our evidence-based centile charts for children from birth to 18 years should help clinicians to update (I Maconochie PhD); and Oxford
clinical and resuscitation guidelines. University Institute of
Biomedical Engineering,
Department of Engineering
Funding National Institute for Health Research, Engineering and Physical Sciences Research Council.
Science, Old Road Campus,
Headington, Oxford, UK
Introduction therefore scarce, and many ranges are probably based (L Tarassenko DPhil, S Fleming)
Heart rate and respiratory rate are key vital signs used to on clinical consensus. Correspondence to:
assess the physiological status of children in many Scoring systems underpinning triage and resuscitation Dr Matthew Thompson, Oxford
University, Department of
clinical settings. They are used as initial measurements protocols for children invariably require measurement of
Primary Health Care, Rosemary
in acutely ill children, and in those undergoing intensive heart rate and respiratory rate. Rates are converted to a Rue Building, Old Road Campus,
monitoring in high-dependency or intensive-care numerical score by applying age-specific thresholds. Headington, Oxford OX3 7LF, UK
settings. During cardiopulmonary resuscitation, these Accurate reference ranges are key to assessing whether matthew.thompson@dphpc.
ox.ac.uk
indices are critical values used to determine responses to vital signs are abnormal. Thresholds that are incorrectly
life-saving interventions. Heart rate and respiratory rate set too low risk overdiagnosing tachycardia or tachypnoea,
remain an integral part of standard clinical assessment whereas those set too high risk missing children with these
of children with acute illnesses,1 and are used in signs. Additionally, a reference range that is applied to an
paediatric early warning scores2,3 and triage screening.4,5 age range that is too broad is likely to lead to incorrect
Early warning scores are used widely in routine clinical assessment of children in some parts of these age groups.
care, and there is good evidence that they can provide We aimed to develop new age-specific centiles for heart
early warning of clinical deterioration of children in rate and respiratory rate in children, derived from a
hospital and in emergency situations.6–9 systematic review of all studies of these vital signs in
Reference ranges for heart rate and respiratory rate in healthy children. We use these centiles to define new
children are published by various international evidence-based reference ranges for healthy children,
organisations (webappendix p 1). Of these publications, which we compare with existing reference ranges. See Online for webappendix
only two guidelines cite sources for their reference
ranges: the pediatric advanced life support guidelines10 Methods
cite two textbooks,11,12 neither of which cite sources for Search strategy and selection criteria
their ranges, and WHO limits for respiratory rate, We searched Medline, Embase, CINAHL and reference
which are based on measurements made in developing lists to identify studies that measured heart rate or
countries.13 Evidence underpinning guidelines is respiratory rate in healthy children between birth and
www.thelancet.com Vol 377 March 19, 2011 1011
2. Articles
single data point to avoid introducing bias on the basis of
Panel : Inclusion and exclusion criteria the following guidelines agreed on before data extraction:
Inclusion criteria (1) if di erent measurement methods were used, data
• Cross-sectional, case-control, or longitudinal study from the least invasive or stressful method were selected;
• Minimum of 20 children (2) for data shown as combined age groups, we selected
• Age range between birth and 18 years data from separate age groups unless the age ranges of
• Objective measurement of heart rate or respiratory rate individual groups were very small (eg, infants between
• Raw data or average measure of heart rate or respiratory rate reported for each age group one and two days of age); (3) we used awake measures
when both awake and asleep measurements were
Exclusion criteria available; (4) we averaged readings across all sleep states
• Preterm infants when many states of sleep were reported; and (5) we
• Children with illnesses likely to affect the cardiac or respiratory system used the first baseline result when more than one
• Children with pacemakers or needing ventilatory support baseline measurement was reported in intervention
• Anaesthetised children studies. These guidelines were chosen to ensure that
• Children known to be taking drugs that would affect the cardiac or respiratory system data used were relevant to clinical setting, in which
• Data gathered from exercising children, without baseline (before intervention) children are typically awake and at rest, to improve the
measurements accuracy of calculated centile charts, and to avoid
• Measurements taken at heights greater than 1000 m above sea level potential confounding factors such as definition of sleep
• Age groups including adults (without subgroups) states or distress due to invasive measurements or
• Age groups spanning more than 10 years (without subgroups) interventions. Combined age groups were separated to
ensure that the most accurate age range was associated
with each data point, but very small age ranges were left
18 years of age, from 1950, to April 14, 2009, with MeSH combined, because we believed that the benefit of
terms and free text. Webappendix p 2 shows the search accurate ages would be small compared with the loss
strategy that was used to identify relevant studies. of accuracy for raw centiles calculated from small
There were no language restrictions. Panel 1 shows the sample sizes.
inclusion and exclusion criteria. SF and MT assessed
eligibility of studies for inclusion, and disagreements Data analysis
were resolved by AP. We calculated the median and representative centiles
MT and IM identified sources of existing reference (1st, 10th, 25th, 75th, 90th, 99th) for data from each
ranges by reviewing paediatric textbooks, resuscitation included study. For studies that did not report relevant
manuals, and resuscitation guidelines from Europe and summary statistics, we estimated them from the mean
North America. To mirror the probable exposure of and standard deviation. We tested for skewness with
clinicians to reference ranges, we concentrated on ranges Pearson’s second skewness coe cient and the quartile
published in resuscitation guidelines, manuals for skewness coe cient (Bowley skewness).14 We reported
standardised clinical training courses, and WHO inter- no skewness in either heart rate or respiratory rate data,
national guidelines (webappendix p 1). These sources are and therefore assumed a normal distribution at each age.
not intended to be exhaustive, because various reference We excluded two outlier values of data spread (one
ranges are published in textbooks and as part of triage standard error, and one set of confidence intervals) as
scores or early warning scores; these reference ranges were they resulted in negative respiratory rates for several
not used in this article because of their heterogeneity. centiles, which is not physiologically plausible.15,16 We did
not identify any outliers in the heart rate data.
Data extraction We created centile charts using kernel regression, a
Data for year of study, participants (age range, number, form of non-parametric curve fitting,17 which avoids
reason for measurements), study setting, method of imposing an excessive degree of constraint on resulting
measurement, and whether children were awake or curves. We adjusted classic kernel regression to account
asleep were extracted by SF and checked by AP. For each for the age range and the sample size associated with
age group, the sample size and the minimum and each data point (webappendix pp 3–4). For heart rate
maximum ages were extracted, with reported summary and respiratory rate, we used kernel regression to fit
statistics (ie, mean, median, centiles, standard deviation, seven curves showing variation related to age, with
confidence intervals, or standard error) for heart rate and values calculated for the median and six representative
respiratory rate. We classed data reported separately centiles from the included studies. These centiles
(ie, for girls and boys, or for ethnic groups) in the same were compared visually with reference ranges in
age group as independent groups. webappendix p 1.
For studies that reported many results for one group of We did subgroup analyses to assess whether setting,
children at a specific age (eg, in di erent phases of sleep, economic development of the country, method of measure-
or using di erent measurement methods), we selected a ment, or awake or asleep state of children had an e ect on
1012 www.thelancet.com Vol 377 March 19, 2011
3. Articles
vital signs after correction for age using centile charts.
Ideally, separate centile charts could be created to compare 2028 potentially relevant studies
subgroups, but many subgroups did not contain su cient identified and screened
data across the full age range to allow such comparison.
263 duplicates excluded
Therefore, mean and standard deviation of measured vital
signs from each study were normalised with centile charts,
1765 potentially relevant studies
so that variations due to age were removed. Normalised and abstracts screened by
data were analysed with one-way analysis of variance, one reviewer
taking into account the size and variation in each study.
Additionally, regression analysis of normalised means, 1393 studies and abstracts excluded
because not relevant
weighted by the sample size of each study, was done to
identify trends related to date of publication.
372 potentially relevant studies
We defined cuto values for heart rate and respiratory and abstracts screened by
rate using data from centile charts by calculating the two reviewers
mean value and rounding it to a whole number, for each
of the 13 age groups covering the full range of ages 212 excluded by applying inclusion
and exclusion criteria
(0–18 years). Age groups were selected to correspond
with changes of about five beats per min for heart rate
160 full text studies retrieved and
and two breaths per min for respiratory rate. assessed by two reviewers
Role of the funding source 94 excluded by applying inclusion
The sponsors of the study had no role in the study and exclusion criteria
design, data collection, data analysis, data interpretation,
or writing of the report. SF had full access to all the data 66 studies included
in the study and had final responsibility for the decision
to submit for publication. 3 new studies identified by
citation search
Results
Figure 1 depicts the study selection process. We identified 69 studies included in the
systematic review
69 studies from 2028 publications. 59 of 69 reported
data for heart rate from 150 080 measurements of
143 346 children, and 20 reported data for respiratory Figure : Flowchart of systematic search
rate from 7565 measurements on 3881 children, with ten
studies reporting data for both vital signs (for scatter 21 362 measurements), manual measurement (six studies,
plots of data see webappendix p 5). 46 studies were cross- 10 228 measurements), echocardiography (four studies,
sectional, 12 longitudinal, and 11 case-control. They were 890 measurements), and pulse oximeters or proprietary
undertaken in 20 di erent countries on four continents heart-rate monitors (six studies, 2798 measure-
(webappendix pp 6–11): 55 in developed countries (as ments; webappendix pp 6–11). Most respiratory rate
defined by the UN statistics division18), seven in measurements were made manually (seven studies,
developing countries, and seven in countries that were 6531 measurements); automated measurements were
judged to be neither developing nor developed. made with strain gauges, thermistors, thoracic impedance,
The number of children per study ranged from 20 to and helium dilution (13 studies; 1034 measurements).
101 259. Studies were done in community settings Figure 2 shows the 1st to 99th centiles of respiratory
(eg, home, school or kindergarten; 27 studies, rate in healthy children from birth to 18 years of age.
26 024 measurements), clinical settings (eg, hospitals, These centiles show decline in respiratory rate from
clinics, or medical centres; 19 studies, 105 982 measure- birth to early adolescence, with the steepest decline
ments), unspecified or many settings (17 studies, apparent in infants during the first 2 years of life.
15 957 measurements), and research laboratories Median respiratory rate decreased by 40% in these
(six studies, 3976 measurements). Most measurements 2 years (44 breaths per min at birth to 26 breaths per
(32 studies, 132 891 measurements) were of awake children, min at 2 years). Proposed cuto s for respiratory rate at
and eight studies (505 measurements) were of asleep each of 13 age groups, from birth to 18 years, are shown
children; 29 studies (18 545 measurements) did not report in webappendix p 12.
the state of wakefulness, or did not distinguish between Subgroup analysis of respiratory rate data showed no
data from awake or asleep children (webappendix pp 6–11). significant di erences on the basis of study setting
Heart rate was measured by electrocardiography in most (p=0·09), economic development of the country in which
studies (31 studies, 114 802 measurements), whereas others the study was done (p=0·83), wakefulness of the child
used automated blood-pressure monitors (12 studies, (p=0·36), or whether manual or automated methods of
www.thelancet.com Vol 377 March 19, 2011 1013
4. Articles
70 Median
Centiles
60
Respiratory rate (breaths per min)
50
40
30
99th
90th
20 75th
10 25th
10th
1st
0
0 1 2 3 6 9 12 2 4 6 8 10 12 14 16 18
Age (months) Age (years)
Figure : Centiles of respiratory rate for healthy children from birth to 18 years of age
A B
70 Advanced paediatric life support Pediatric advanced life support
Median Median
Centiles (1, 10, 25, 75, 90, 99) Centiles (1, 10, 25, 75, 90, 99)
60
Respiratory rate (breaths per minute)
50
40
30
20
10
0
0 2 4 6 8 10 12 14 16 18 0 2 4 6 8 10 12 14 16 18
Age (years) Age (years)
Figure : Comparison of respiratory rate centiles with paediatric reference ranges from the advanced paediatric life support (A) and pediatric advanced life
support (B) guidelines
measurement were used (p=1·00). Regression analysis paediatric life support course.19,20 Examples of this
of study publication dates did not show any significant disparity can be seen in figure 3. For example, for
di erence in measured respiratory rate (p=0·19). children under 1 year of age, the advanced paediatric
Figure 3 shows how the centiles derived from our life support upper limit for respiratory rate is 40 breaths
systematic review compare with two existing reference per min, which is roughly the median value on our
ranges—advanced paediatric life support17 and pediatric centile chart for children in this age range. For children
advanced life support.10 None of the existing reference over 12 years of age, the pediatric advanced life support
ranges in webappendix p 1 showed good agreement upper limit of 16 breaths per min is below the median
with our centile charts across the full age range, but the value on our centile chart for much of this age range.
best agreement was seen with the ranges cited by We noted that one median value of respiratory rate for
advanced paediatric life support and European children between 0 and 6 months of age21 was much
1014 www.thelancet.com Vol 377 March 19, 2011
5. Articles
200 Median
Centiles
180
160
140
Heart rate (beats per min)
120 99th
100 90th
75th
80
60
25th
10th
40
1st
20
0
0 1 2 3 6 9 12 2 4 6 8 10 12 14 16 18
Age (months) Age (years)
Figure : Centiles of heart rate for healthy children from birth to 18 years of age
A B
200 Advanced paediatric life support Pediatric advanced life support
Median Median
Centiles (1, 10, 25, 75, 90, 99) Centiles (1, 10, 25, 75, 90, 99)
180
160
140
Heart rate (beats per minute)
120
100
80
60
40
20
0
0 2 4 6 8 10 12 14 16 18 0 2 4 6 8 10 12 14 16 18
Age (years) Age (years)
Figure : Comparison of heart rate centiles with paediatric reference ranges from the advanced paediatric life support (A) and pediatric advanced life
support (B) guidelines
higher than that reported in many other studies. However, point would not bias the estimation, and so we did not
the spread of measured respiratory rates at these ages is judge this to be an outlier.
very large (webappendix p 5). Since the kernel-regression Figure 4 shows 1st to 99th centiles of heart rate versus
method used to create the centile charts accounts for age, with the proposed cuto s for heart rate shown in
both age range and sample size, we decided that this data webappendix p 12. These centiles show a decline in heart
www.thelancet.com Vol 377 March 19, 2011 1015
6. Articles
rate with age. The first section of figure 4, showing the score2,3 assessment methods refer to advanced paediatric
heart rate centile chart for infants under age 1 year, shows life support reference ranges.
a small peak in heart rate at 1 month. This peak is not an For clinical assessment of children, our findings
artifact of the modelling method, but can be seen in suggest that current consensus-based reference ranges
primary data from various studies that report many heart for heart rate and respiratory rate should be updated with
rate measurements of infants under age 1 year.22–27 Median new thresholds on the basis of our proposed centile
heart rate in this age range increases from 127 beats per charts, especially for those age groups where there are
min at birth, reaching a maximum of 145 beats per min large di erences between current ranges and our centile
at about 1 month of age, before decreasing to 113 beats charts, indicating that many children are likely to be
per min by age 2 years. misclassified. Normal ranges, such as those published in
Subgroup analysis showed that heart rates measured in textbooks and clinical handbooks, should also be updated
community settings were higher (p<0·0001) than those in view of our results. To assist the development of cuto
measured in clinical or laboratory settings, and rates values for use in clinical settings, we provide values
measured with automated techniques (eg, electro- corresponding to the median and six di erent centiles
cardiography) were higher (p=0·0011) than those for both heart rate and respiratory rate for 13 age groups
measured manually. Heart rates of children in developing between birth and 18 years of age.
countries were also higher than those measured in By providing several di erent centiles for children of
developed countries (p<0·0001). Although heart rates all ages, we have provided clinicians and those
measured in awake children tended to be higher than responsible for developing clinical guidelines and early
those of asleep children, the di erence was not significant warning scores with su cient information to select
(p=0·06). Regression analysis of study publication dates cuto values that are most appropriate to the type of
showed that there was a small but significant trend in clinical setting in which they are likely to be used.
heart rate (p<0·0001), with older studies reporting lower Selection of appropriate cuto values should take
heart rates than did recent studies. into account the consequences associated with
Figure 5 shows a comparison of reference ranges from misclassification of both healthy and unwell children.
advanced paediatric life support and pediatric advanced For many measurements made over time, centile charts
life support guidelines with our centiles of heart rate. could also be used to assess magnitude of changes in
Comparisons were also made between our centile chart heart rate or respiratory rate.
and other reference ranges cited in webappendix p 1. As For accurate measurement of heart rate in children,
with respiratory rate, none of these ranges showed good clinicians should be aware that manual measurement of
agreement with our centile chart across the full age heart rates, which is common practice in many settings,
range, from birth to 18 years of age. Best agreement could underestimate true rates. In these children,
between reference ranges for heart rate and our centile measurement of heart rate by automated methods
chart was with advanced paediatric life support and provides accurate results. Professional bodies responsible
advanced trauma life support reference ranges,19,28 for publication of guidelines and scoring systems should
although both these also showed substantial dis- consider revising current thresholds, by selecting heart
agreement with our centile charts. For example, in rate and respiratory rate values that represent an upper
children from 2–5 years of age, the advanced paediatric centile for each age group; to assist with this selection,
life support lower limit for heart rate is 95 beats per min, we propose to make the data used to create our centiles
which roughly correlates with the 25th centile of our of heart rate and respiratory rate (figures 2 and 4) freely
chart, and reaches the median heart rate at the upper available upon request.
end of the age range. In children 2–10 years of age, the A key strength of our approach is that the centile
upper limit for pediatric advanced life support is charts were created with kernel regression, a non-
140 beats per min, which lies above the 99th centile of parametric modelling technique that avoids imposing
our chart for most of the age range. any particular form onto the shape of the centile charts;
this is important for this type of data, because there is
Discussion no reason to expect that it will follow an analytical
Our centile charts of respiratory rate and heart rate in function such as a straight line or exponential curve.
children provide new evidence-based reference ranges However, several methodological limitations are worth
for these vital signs. We have shown that there is noting. Our systematic review included an extensive
substantial disagreement between these reference search of published works from three large databases,
ranges, and those currently cited in international with no restriction on language or country of
paediatric guidelines, such as those shown in publication. However, our search strategy and inclusion
webappendix p 1, which are used widely as the basis for criteria could have missed relevant studies, particularly
clinical decisions when interpreting these signs in studies published before 1960. We excluded 13 studies
children (panel 2). For example, the paediatric advanced because we were not able to extract necessary data or
warning score and Brighton paediatric early warning could not obtain full copies, and we did not attempt to
1016 www.thelancet.com Vol 377 March 19, 2011
7. Articles
and specificity will be dependent on age and accuracy of
Panel : Research in context previous reference ranges. For existing advanced paediatric
Systematic Review life support reference ranges, which had the greatest
We searched Medline, Embase, CINAHL, and reference lists to agreement with our centiles, figures 3 and 5 suggest that a
identify studies that measured heart rate or respiratory rate in large number of children are currently misclassified. For
healthy children between birth and 18 years of age, from 1950, example, at 10 years of age the advanced paediatric life
to April 14, 2009. Measurements during exercise, at altitude, support cuto for heart rate classifies about 40% of healthy
or of children whose illness was likely to affect their heart rate children as abnormal, and the cuto for respiratory rate
or respiratory rate were excluded. Non-parametric kernel misclassifies about 63% of healthy children. Furthermore,
regression taking into account age range and sample size was on the basis of age distribution of children typically seen
used to construct centile charts based on extracted data. in a primary care setting,27 we estimate that the specificity
of advanced paediatric life support could be improved by
Interpretation as much as 20% for heart rate and 51% for respiratory rate
Substantial disagreement exists between consensus-based if revised centile charts are used. The validity of our
reference ranges for heart rate and respiratory rate in children. centiles and any cuto s derived from them should be
These reference ranges do not correspond with centile charts assessed both in healthy children and in those presenting
derived from our systematic review of observational studies, with a range of diseases.
which includes data from children of all ages. We have shown that existing reference ranges for heart
rate and respiratory rate in children are inconsistent, and
contact original authors to obtain individual patient do not agree with centile charts derived from a systematic
data, because gathering such data would not have been review of observational studies. This finding has
feasible in view of the number of studies included, potentially wide-ranging implications for clinical
some of which were published over 25 years ago. assessment of children, and for design of resuscitation
We noted pronounced heterogeneity of settings in guidelines, triage scores, and early warning systems.
which childrens’ heart rate and respiratory rate were Contributors
measured, their state of wakefulness, and methods of SF and MT identified eligible studies. MT and IM identified sources of
measurement, all of which could have an e ect on the existing reference ranges. SF and AP extracted data. SF and RS did the
statistical analysis. All authors contributed to the writing of this article.
measured variables. As reported, subgroup analysis
showed that setting, method of measurement, and Conflicts of interest
IM is the UK chair for the European Paediatric Life Support Course, and
economic development all had a significant e ect on a member of the European Guidelines writing team.
heart rate in children (setting p<0·0001; method of
Acknowledgments
measurement p=0·0011; economic development We thank Nia Roberts, Ruth Davis, Robert Oakey, Lee Wallis, and Jill Mant
p<0·0001), but not on respiratory rate (webappendix p 13). for assistance and advice, and the National Institute of Health Research
We excluded children with illnesses that might a ect (NIHR) school for primary care research, the Engineering and Physical
the heart rate or respiratory rate, and measurements Sciences Research Council, and the NIHR Biomedical Research Centre
Programme for their support. This study was funded by the NIHR
known to be made during exertion, but many studies programme grant RP-PG-0407-10347: Development and Implementation
did not report whether children were settled or agitated of New Diagnostic Processes and Technologies in Primary Care.
during measurement, which could have introduced References
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