Normal values for pediatric vital signs may vary with age, gender, height, level of anxiety and the technique that you use measure them. Numerous bodies have worked to create normal reference ranges for vital signs in different age groups, however there is some disagreement between groups as to what is truly normal.  A good approach is to keep an approximate normal value in mind, and to always interpret vitals based on the clinical context.

For a more detailed approach to this topic, see our podcast on "Pediatric Vital Signs."

(click the image for a full screen hand-out)

Heart Rate:

Note: A major 2011 systematic review of pediatric heart rate and respiratory rate suggests that previously published reference ranges may require updating. Updated centile charts based on this study can be found here: http://madox.org/tools-and-resources

Respiratory Rate:

Note: A major 2011 systematic review of pediatric heart rate and respiratory rate suggests that previously published reference ranges may require updating. Updated centile charts based on this study can be found here: http://madox.org/tools-and-resources

Blood Pressure:           

For precise determination of a child’s blood pressure percentile, as is needed to diagnose hypertension, specific reference ranges have been developed based on a child’s age, gender, and height.  You can find these tables here: http://www.nhlbi.nih.gov/health-pro/guidelines/current/hypertension-pediatric-jnc-4/blood-pressure-tables.  You can find a handy calculator for determining blood pressure percentiles on UpToDate or other medical apps.

Temperature:

Normal values for temperature do not vary significantly with age. The type of thermometer will alter readings, and accuracy.

The CPS recommends axillary, tympanic and temporal artery thermometers for screening, and rectal and oral thermometers for definitive measurement.

Pulse Oximetry

Normal pediatric pulse oximetry (SPO2) values have not yet been firmly established. SPO2 is lower in the immediate newborn period. Beyond this period, normal levels are stable with age. Generally, a SPO2 of <92% should be a cause of concern and may suggest a respiratory disease or cyanotic heart disease.

References

1. Avner, J. Acute Fever. Pediatrics in Review. 2009 Jan 1; 30(1):5-13. Available from: http://pedsinreview.aappublications.org/content/30/1/5.extract
2. Chameides L. Pediatrics Advanced Life Support: Provider Manual. American Heart Association; 2012.
3. Drutz E. The pediatric physical examination: General principles and standard measurements. UpToDate. 2013 Aug 13 [cited 2015 Feb 15]. Available from: http://www.uptodate.com/contents/the-pediatric-physical-examination-general-principles-and-standard-measurements
4. Fleming S, Thompson M, Stevens R, Heneghan C, Pluddemann A, Maconochie I, Tarassenko L, Mant D. Normal ranges of heart rate and respiratory rate in children from birth to 18 years: a systematic review of observational studies. Lancet. 2011Mar 19;377(9770):1011-1018.
5. Fouzas S, Priftis KN, Anthracopoulos MB. Pulse Oximetry in Pediatric Practice. Pediatrics. 2011 Oct 1; 128(4):740-752. Available from: http://pediatrics.aappublications.org/content/128/4/740.full
6. Leduc D, Woods S. Temperature measurement in paediatrics.” Canadian Paediatrics Society Position Statement. Posted: 2000 Jan 1. Reaffirmed: 2013 Jan 30 [cited 2015 Feb 15]. Available from: http://www.cps.ca/en/documents/position/temperature-measurement
7. McGee S. Evidence Based Physical Diagnosis, 3^rd Edition. Saunders. 2012.
8. National High Blood Pressure Education Program Working Group. Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents. National Institute of Health. 2005. Available from: http://www.nhlbi.nih.gov/health-pro/guidelines/current/hypertension-pediatric-jnc-4/blood-pressure-tables

Surgery 101 is an online learning resource developed by students, residents and faculty at the University of Alberta.  It offers free open-access podcasts and resources for medical students to learn all things surgical. While the focus may be on Surgery, a number of these podcasts review important presentations in Pediatrics that learners should be familiar with.

In this episode, Dr. Bryan Dicken, a Pediatric General Surgeon, addresses the topic of pyloric stenosis. Listen and learn:

• Why you need to know this
• What you should look for on history and physical
• How to treat a child with pyloric stenosis

Access the podcast here at Surgery 101: Pyloric Stenosis.

Surgery 101 is an online learning resource developed by students, residents and faculty at the University of Alberta.  It offers free open-access podcasts and resources for medical students to learn all things surgical. While the focus may be on Surgery, a number of these podcasts review important presentations in Pediatrics that learners should be familiar with.

In this episode, Dr. Jaret Olsen, a Pediatric Plastic Surgeon at the University of Alberta, addresses the topic of cleft lip and palate. Learning points include:

• Inheritance patterns of the conditions
• Management of problems with feeding, middle ear infections, speech and facial growth

Access the podcast here at Surgery 101: Cleft Lip and Palate.

Surgery 101 is an online learning resource developed by students, residents and faculty at the University of Alberta.  It offers free open-access podcasts and resources for medical students to learn all things surgical. While the focus may be on Surgery, a number of these podcasts review important presentations in Pediatrics that learners should be familiar with.

In this episode, Dr. Parveen Boora, a General Surgeon, addresses the topic of appendicitis. While this topic isn't exclusively about Pediatrics, this is a presentation that every Pediatrician should be aware of. Topics covered include:

• The pathophysiology of the condition
• How acute appendicitis presents
• How to diagnose the disease
• Treatment options
• Post-op care

Access the podcast here at Surgery 101: Appendicitis.

For a more general approach to acute abdomnal pain in children, see our PedsCases podcast on Acute Abdominal Pain.

Surgery 101 is an online learning resource developed by students, residents and faculty at the University of Alberta.  It offers free open-access podcasts and resources for medical students to learn all things surgical. While the focus may be on Surgery, a number of these podcasts review important presentations in Pediatrics that learners should be familiar with.

In this episode, Dr. Vivek Mehta, a Pediatric Neurosurgeon, addresses the topic of pediatric brain tumours. After listening to this episode, learners will be able to:

• Understand the commonality of pediatric brain tumours
• Describe the most common symptoms seen in children suspected of having a brain tumor
• Describe the steps in determining what to do about the tumor
• Describe the characteristics associated with the two most common pediatric brain tumors

Access the podcast here at Surgery 101: Pediatric Brain Tumors.

Surgery 101 is an online learning resource developed by students, residents and faculty at the University of Alberta.  It offers free open-access podcasts and resources for medical students to learn all things surgical. While the focus may be on Surgery, a number of these podcasts review important presentations in Pediatrics that learners should be familiar with.

In this episode, Mitch Wilson, a medical student at the University of Alberta (at the time of recording) and Dr. Jeff Pugh, a Pediatric Neurosurgeon, address the topic of hydrocephalus. The learning objectives of this podcast include:

• Define the term "hydrocephalus" and list three mechanisms by which hydrocephalus can develop.
• Describe the signs and symptoms of hydrocephalus and describe common diagnostic tests.
• Outline the surgical options for the management of hydrocephalus.

Access the podcast here at Surgery 101: Hydrocephalus.

Surgery 101 is an online learning resource developed by students, residents and faculty at the University of Alberta.  It offers free open-access podcasts and resources for medical students to learn all things surgical. While the focus may be on Surgery, a number of these podcasts review important presentations in Pediatrics that learners should be familiar with.

In this episode, Dr. Peter Metcalfe, a Pediatric Urologist, address common problems in his in his field. Conditions covered in this podcast include:

• Problems with the foreskin.
• The undescended testicle.
• Hypospadias.
• Ambiguous genitalia.

Access the podcast here at Surgery 101: Pediatric Urology.

For more information Pediatric Urology, see our Pedscases podcast on Urologic Emergencies.

The following was adapted from the Canadian Paediatric Society's statement on "The toddler who is falling off the growth chart." Please see the full statement for the full recommendations from the Canadian Paediatric Society. For more information, please see our PedsCases podcast on "Failure to Thrive."

Background:

Problems in a child's health or nutrition almost always affect growth.  A significant decrease in growth velocity outside of normal variations is termed failure to thrive and warrants evaluation. If detected early and treated appropriately, growth failure may be reversible.  If not, the child's ultimate height may be affected. Therefore it is important for physicians to closely monitor the weight, length/height and head circumference of developing children to detect changes in growth pattern. The WHO growth charts are now the standard for monitoring growth in children. 

Most children follow the same percentile for weight and height throughout childhood, however birth weight and height does not always reflect a child's genetic potential. Intrauterine growth is affected by a number of factors including maternal nutrition, smoking, placental insufficiency or gestational diabetes. After the birth the child may have "catch-up" or "catch-down growth towards their genetic potential in the first 2-3 years of life.  Nutrition can also affect early growth patterns with breastfed infants showing faster growth in the first six months of life than formula-fed infants. After the age of three, there should be no more changes in growth percentile until puberty.

Etiology:

The CPS lists the following as the leading causes of growth failure:

• Inadequate caloric intake - Either because the child is eating poorly (most common), anorexia associated with chronic disease, or lacking oral and/r eating skills.
• Increased energy losses - Either due to emesis or malabsorption from pancreatic disease (eg. Cystic fibrosis), cholestatic liver disease or intestinal disease (eg. Celiac disease, Crohn's  disease).
• Increased energy needs - Either due to an underlying chronic condition or chronic or recurrent infections (ie. Primary immune deficiencies).
• Endocrine problem - Including hypothyroidism or a growth hormone deficiency.
• Other (rare) - Diencephalic tumours or renal tubular acidosis.

Evaluation:

First, ensure that growth has been measured accurately and in the same conditions. For example the child should be undressed, on the same scale and using a height gauge.

Mid-parental height can be used to estimate a child's genetic potential:

• Boys = (Father's height + Mother's height)/2 + 6.5 cm +/- 8.5 cm
• Girls = (Father's height + Mother's height)/2 - 6.5 cm +/- 8.5 cm

A complete history and physical should be completed, including a detailed nutrition and diet history:

• Assess the eating environment including distractions.
• Is the child easy to feed?
• Have there been any negative experiences with food, including reflux or allergies?
• Has there been difficulty introducing new foods including solids, textures or weaning from breastmilk?

Healthcare providers should be sensitive to questioning around parenting skills and approaches to food, as this can be a very stressful situation for parents.

With the help of a nutritionist, caloric intake can be estimated from a 72-hour food diary and compared to requirements.  Malabsorption should be suspected in a child who has growth failure despite having a higher caloric intake than would be need.

Investigations should be ordered in a step-wise manner, and should be guided by a differential diagnosis. For a detailed list of suggested investigations please see the complete statement.

Intervention:

After completing assessment, if no disease is detected, it is important to reassure that their child is healthy and to continue to monitor growth as you would any other child. If a disease is diagnosed treat the underlying cause.

If the child has inadequate caloric intake, assess caloric needs (cal/kg/day) using the formula:

• Caloric needs =  Caloric needs for weight age x (ideal weight/actual weight)

A nutritionist can suggest changes to the child's diet to increase calorie density, including adding high-calorie formulas to supplement after meals.

Pharmacologic intervention including cyproheptadine should only be used in consultation with an expert in the field, but may help make the child feel hunger and feel happier to eat.

Tube feeding should be considered only when the underlying disease is made worse by poor nutritional status, oral feeding is unsafe and all other options have been exhausted.  Insertion of a nasogastric tube can be traumatic for a child and family and can lead to oral aversion in the future.

Psychosocial interventions can work to reduce parental and child anxiety around feeding, return control of feeding to the child and work to make mealtimes a positive family experience.

Last updated by PedsCases: May 1, 2015

The following was adapted from the Canadian Paediatric Society's statement on "Multidisciplinary Guidelines on the Identification, Investigation and Management of Suspected Abusive Head Trauma." Please see the full statement for the full recommendations from the Canadian Paediatric Society. For more information, please see our PedsCases podcast on "Physical Abuse in Children."

Background

Abusive Head Trauma (AHT) is a specific form of traumatic brain injury, defined with a constellation of signs, symptoms, laborratory investigations, imaging and pathologic findings that are consequence of violent shaking, impact or a combination of the two. AHT usually is seen in infants and young children but can occur in older children. The name AHT has been adopted in favour of past terms including Shaken Baby Syndrome as a more precise descriptor of the range of possible injuries.

Presenting features of AHT are often non-specific. There may be no external signs of injury so it is important to consider AHT in the differential in any child with altered level of responsiveness without a clear etiology. Presenting features may include:

• Altered level of responsiveness
• Lethargy
• Decreased feeding
• Irritability
• Vomiting
• Respiratory distress or apnea
• Seizures

Characteristic injuries which may be seen on examination or imaging include:

• Intracranial haemorrhage
• Retinal haemorrhage
• Brain injury
• Fractures of the skull, ribs and the metaphyses of long bones

The identification, investigation and management of AHT is complex and requires a multidisciplinary approach.  These guidelines outline the role of each discipline, and include overall guiding principles for managing this complex subject.  This summary, targeted for learners in medicine, will focus on the role of the health sector.  For more details on the complexity of this issue please see the completestatement.

General Principles

The following general principles apply to all professionals involved in a suspected case of AHT:

• Protection of the child and other children in the family is of paramount importance, and the child should be provided the best quality of medical care available.
• When AHT is suspected it is mandatory to provide early notification to child protection so they can begin their investigation.  Child protection will notify the police if warranted.
• One member of the health care team should be designated to share information and convene a case conference as soon as appropriate.
• Professionals should avoid contamination of the evidence.  Statements and actions (such as probing questions) from a professional can affect the process or outcome of an investigation.
• When talking to familes, be cautious about providing information about possible mechanisms of injury.  It is best to simply say that the child's injuries are the result of trauma.
• Professionals should document all encounters with the patient and involved parties.  All documentation must be specific, easy to understand and available to the treatment team as soon as possible. Documentation should be accompanied by diagrams, and/or photographs to provide clarity where appropriate. Caution should be taken in making definitive statements about the cause of injury before assessment is complete.
• Consider if other children in the family or in the home may be at risk.  Make plans to evaluate and protect other children as necessary.
• All professionals may be required to testify regarding their assessments in court proceedings.

Health Sector

The health sector team involved may include medical, surgical and nursing staff. Primary responsibilities of this team include diagnosis and management of medical concerns.

A complete history and physical exam should be completed.  It is important to note that the accompanying caregiver may have no knowledge of the injury and/or may not give a complete or accurate history.  The physical exam should look for any associated injuries with special attention to examination of the nervous system and eyes.

Every child should be assessed by an experienced opthalmologist with an indirect opthalmoscope and dilated pupils.  A child with diffuse multilayered retinal hemorrhages suggests AHT. The documentation of retinal findings is essential, with photographs if possible.

Imaging of the head is necessary in all suspected cases of AHT. A CT scan is indicated acutely, and an MRI may be used later to provide additional information. Findings of a subdural hematoma or cerebral edema support a diagnosis of AHT.

A skeletal survey is required to detect bony injury. A bone scan may be used to identify some subtle and acute bony injuries.

Investigations should include a CBC and coagulation studies.  Additional tests may be indicated to confirm or rule out other diagnoses.

Consultations with the following physicians may be required (preferably with pediatric expertise):

• Physician with experience in child maltreatment
• Opthamologist
• Neurosurgeon
• Neurologist
• Radiology

These guidelines do not discuss detailed medical management of a child with AHT, however the level of care may vary widely depending on the severity of the injury.

In the event of a child's death, the post-mortem examination should be conducted according with local legislations for deaths of children under suspicious circumstances.

Other Professionals

The roles of other professionals include, but are not limited to:

• Psychosocial Professionals (Social Workers, Psychologists, Spiritual Care Providers) - Assessment of capacity and risk to the child.  Provision of emotional, physical, financial and spiritual support. Discharge planning and referral to communities agencies
• Child Protection Agencies - Immediately contacting the police to conduct a joint investigation.  Hold primary responsibility for the safety of the child during the investigation. Decisions related to status, access, supervision and placement.
• Police - Conduct a joint investigation with child protection.  Hold primary responsibility for the criminal investigation. Act as a liaison between Crown prosecutors and other professionals involved.
• Medical Examiners and Coroners - Report all unexplained or unexpected child deaths to the the child and family service agency. Perform an autopsy. Publish and annual report on child deaths.
• Crown Prosecutors - Lead the prosecution whenever possible. Determine if there is sufficient evidence to proceed to trial. Obtain and prepare appropriate expert witnesses in the field of AHT.

For more details on the roles of other professionals, please see the complete statement.

Last updated by PedsCases: May 8, 2015

Thanks to all of our users for their ongoing support.  In Canada, we are enjoying our brief months of summer, but we are still hard at work to bring more great Pediatric #FOAMed content. Our website continues to grow, and this week we have passed 600,000 podcast downloads.

PedsCases had a big year of growth in 2015 and we have big plans in store for 2016. Our podcasts recently passed 750,000 downloads. Thanks again to all of our users and contributors who work to create excellent free open-access medical education resources. 

In the past few months we have released a number of new learning resources.

• New podcasts on topics including Neonatal Abstinence Syndrome, ALTEs, Asthma, Pediatric Advanced Life Support and Neonatal Resuscitation.
• A new series of collaborative podcasts reviewing new CPS Guidelines.
• New cases on Asthma, and Pyloric Stenosis.
• New videos on the newborn exam (it's still coming!), and interpretation of chest x-ray.

The following was adapted from the Canadian Paediatric Society’s statement on “Uncomplicated pneumonia in healthy Canadian children and youth: Practice points for management” (Dec 2015). Please see the full statement for the full recommendations from the Canadian Paediatric Society.

Background:

Pneumonia is an acute inflammation of the parenchyma of the lower respiratory tract caused by a microbial pathogen. An estimated 1 in 20 children younger than five years of age will contract pneumonia each year. These guidelines apply to uncomplicated, community-acquired pneumonia in healthy, immunized children.  They should not be used for children with severe pulmonary pathology, chronic or recurrent pneumonia, aspiration pneumonia or in immunocompromised children as they may require more intensive management. For management of complicated pneumonia or empyema, click here.

Etiology:

Uncomplicated pneumonia can be caused by three broad categories of pathogens. The likelihood of different etiologies varies based on the child's age, the season and the community. 

• Viral Pneumonia – Respiratory syncytial virus (RSV), Parainfluenza virus, Human metapneumovirus and Influenza.
• Typical Bacterial Pneumonia: Streptococcus pneumoniae most commonly. Rarely Haemophilus influenzae type b (in vaccinated children), Group A Strep, or Staphylococcus aureus (including MRSA in high-risk communities)
• Atypical Bacterial Pneumonia: Mycoplasma pneumoniae and Chlamydophila pneumoniae.

In infants and preschool children, viruses are the most common cause, but some infections may be caused by typical bacteria.  In school-age children atypical bacteria emerge that are rarely seen in younger children, and viruses (with the exception of influenza) become less common.

Signs and Symptoms:

In contrast to adult presentations of pneumonia, pediatric pneumonia can be very non-specific, especially in infants and younger children. Acute onset of a fever, cough, difficulty breathing, vomiting, poor feeding or simply a lack of interest in normal activities are common symptoms. Children may present with chest or abdominal pain. Rigors favour a bacterial cause. Preceding malaise and headache may suggest an atypical cause, while preceding fever and myalgias may suggest influenza during flu season.

The clinical exam should specifically note presence/absence of fever, signs of increased work of breathing, tachypnea and hydration status. Normal O² saturation DOES NOT exclude pneumonia. Signs of consolidation include dullness to percussion, increased tactile fremitus, reduced vesicular breath sounds and increased bronchial breath sounds. Signs of effusion include dullness to percussion, decreased tactile fremitus, decreased or absent breath sounds.

Investigations

Chest radiographs (CXR) should be used to diagnosis pneumonia whenever possible (particularly for avoiding of over-prescription of antibiotics).  They should also be repeated to re-assess deterioration, or lack of improvement following a diagnosis. CXRs are NOT indicated to track illness improvement. The radiographic changes associated with pneumonia take 4-6 weeks to fully resolve.  Thus, when a patient is showing clinical improvement, there is no indication to repeat a CXR. Viral pneumonia may be more likely if the CXR shows poorly defined nodules, patchy areas of opacity, variable hyperinflation with NO evidence of effusion.

Predominant wheeze suggests that asthma or bronchiolitis is a more likely cause than pneumonia and a CXR should not be ordered.

Other investigations, including CBC with differential, blood culture, sputum samples, pleural fluid culture or nasopharyngeal (NPA) swabs are generally not required, but may be used for children who are worsening or hospitalized. If NPA serology is completed and identifies a viral pathogen, antibiotic therapy should not be administered.  However, especially with the possibility of a secondary bacterial infection, it is important to closely monitor the patient for appropriate clinical improvement.

Management:

Most children with pneumonia can be managed as outpatients. Admission is generally indicated if a child has inadequate oral intake, is unable to oral medications, has respiratory compromise or complicated pneumonia.

If viral pneumonia is the most probable cause based on the season and CXR findings or confirmed on NPA, manage with supportive care and no antibiotics. Consider antivirals if influenza suspected, particularly in hospitalized children.

If clinical picture and CXR are compatible, with bacterial pneumonia should receive antibiotic therapy to cover S. pneumoniae.

• Outpatient – Oral Amoxicillin
• Inpatient (Moderate) – IV Ampicillin
• Inpatient (Severe) – IV Ceftriaxone or Cefotaxime. Consider adding Vancomycin in MRSA suspected.

If another pathogen is detected in pleural fluid or blood, modify antibiotics based on susceptibility. The role of antibiotics in atypical pneumonia is unknown as most children recover without macrolides.  Reserve macrolide antibiotics for children who are more seriously ill.

Expected clinical course and follow-up:

Clinical improvement should be evident within 48 hours of treatment with bacterial pneumonia, but may take longer for viral pneumonia.  If clinical improvement occurs, repeat CXR is not recommended as radiographic resolution can take four to six weeks. If the child does not improve as suspected, repeat a CXR to look for complications or other causes.

Key Take-Home Points

1. Recognize that the clinical presentation of pneumonia can be very non-specific, especially in infants and younger children.
2. Chest radiographs should be used to diagnosis pneumonia whenever possible.  They should also be repeated to re-assess deterioration, or lack of improvement following a diagnosis.
3. Chest radiographs are NOT indicated to track illness improvement.
4. Nasopharyngeal swabs for viral serology are not indicated for outpatients with mild to moderate symptoms, but should be completed in any child admitted to hospital.
5. Bacterial pneumonia should improve within 48 hours of initiation of appropriate antibiotic therapy, (viral may take slightly longer). Be sure to re-evaluate diagnosis if this improvement is not observed.

Last updated by PedsCases: February 29, 2016

The first few months of 2016 have been busy at PedsCases - we've just surpassed 825,000 podcast downloads! Since sending out a CFMS update, we've received a large number of requests from medical students to get involved with PedsCases which is fantastic! As always, thanks again to all of our users and contributors who work to create excellent free open-access medical education resources. 

In the past few months we have released a number of new learning resources.

The following was adapted from the Canadian Paediatric Society’s statement on the “Management of Acute Otitis Media”. Please see the full statement for the full recommendations from the Canadian Paediatric Society.

Etiology:

Viral upper respiratory tract infections frequently lead to middle ear effusions.  These effusions can become populated with viruses or bacteria, leading to acute otitis media (AOM). Cases of viral AOM are likely to have spontaneous resolution without therapy.  Bacterial causes are most commonly Streptococcus pneumoniaie, Haemophilus influenzae and Moraxella catarrhalis. 

Diagnosis:

Proper diagnosis of acute otitis media requires:

1. Signs of a middle ear effusion (eg. immobile tympanic membrane with or without opacification, loss of boney landmarks, or a tympanic membrane that has ruptured)
2. Middle ear inflammation (eg. bulging of discouloured tympanic membrane)
3. Acute onset of symptoms

General symptoms of AOM include rapid onset of ear pain or unexplained irritability in a preverbal child.

Treatment:

Watchful waiting for 24 to 48h with assurance is appropriate when:

1. Otherwise healthy child older than six months of age
2. No craniofacial abnormalities
3. Mild clinical signs and symptoms - No perforation, fever <39 degrees in the absence of antipyretics, <48 hours of illness, alert, responsive, able to sleep.
4. Follow-up by family likely to occur

General assurance includes advice regarding analgesia and for the family to return if the child is not improved in that time period. Families can also be provided a deferred prescription (a prescription to be filled at their own discretion).

If you are deciding to treat, then first line therapy is high-dose amoxicillin at 75 mg/kg/day to 90 mg/kg/day divided bid for five days in children older than two years of age and 10 days for younger children or those with frequent or complicated AOM (ie. perforation.)

The influenza vaccine and pneumococcal conjugate vaccine should be offered to all children of appropriate age.

Last updated by PedsCases: April 10, 2016.

For a more detailed approach to this topic, see our podcast on "Pediatric Vital Signs." Click the image for a full screen handout.

Heart Rate:

Respiratory Rate:

Blood Pressure:           

For diagnosis of hypertension refer to the NHBPEP Reference tables. You can find calculators for determining blood pressure percentiles on UpToDate or other medical apps.

Temperature:

Temperature ranges do not vary with age. Axillary, tympanic and temporal temps for screening (less accurate). Rectal and oral temps for definitive measurement (unless contraindication).

Pulse Oximetry

Normal pediatric pulse oximetry (SPO2) values have not yet been firmly established. SPO2 is lower in the immediate newborn period. Beyond this period, normal levels are stable with age. Generally, a SPO2 of <92% should be a cause of concern and may suggest a respiratory disease or cyanotic heart disease.

References

1. Heart and Stroke Foundation of Canada. 2015 Handbook of Emergency Cardiovascular Care for Healthcare Providers. 2015 Nov. p. 77.
2. Fleming S, Thompson M, Stevens R, Heneghan C, Pluddemann A, Maconochie I, Tarassenko L, Mant D. Normal ranges of heart rate and respiratory rate in children from birth to 18 years: a systematic review of observational studies. Lancet. 2011Mar 19;377(9770):1011-1018.
3. Fouzas S, Priftis KN, Anthracopoulos MB. Pulse Oximetry in Pediatric Practice. Pediatrics. 2011 Oct 1; 128(4):740-752. Available from: http://pediatrics.aappublications.org/content/128/4/740.full
4. Leduc D, Woods S. Temperature measurement in paediatrics.” Canadian Paediatrics Society Position Statement. Posted: 2000 Jan 1. Updated: 2015 Oct 15 [cited 2016 Apr 22]. Available from: http://www.cps.ca/en/documents/position/temperature-measurement
5. McGee S. Evidence Based Physical Diagnosis, 3^rd Edition. Saunders. 2012.
6. National High Blood Pressure Education Program Working Group. Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents. National Institute of Health. 2005. Available from: http://www.nhlbi.nih.gov/health-pro/guidelines/current/hypertension-pediatric-jnc-4/blood-pressure-tables

As we enter the warm days of summer, our team at PedsCases continues to grow and we have recently past 900,000 podcast downloads.  We would like to introduce our two PedsCases summer interns, Jeff Bennett and Nikita-Kiran Singh.  Nikita and Jeff will be working throughout the summer to develop exciting new content for PedsCases.  We are extremely grateful to the University of Alberta Department of Pediatrics for sponsoring our summer interns. You can learn more about Nikita, Jeff and the rest of our team here.

In the past few months we have released a number of new learning resources.

We are thrilled to announce that PedsCases has reached over 1 million podcast downloads.  Thank you to all of the student, resident and staff contributors from across Canada who have worked to put together this great resource for learners, and thank you to all of the listeners for your support. Stay tuned for more podcasts, cases and videos.

The following was adapted from the “Joint Statement on Safe Sleep: Preventing Sudden Infant Deaths in Canada.” This statement was a collaboration between the Canadian Paediatric Society, the Canadian Foundation for the Study of Infant Deaths, the Canadian Institute of Child Health, Health Canada, and the Public Health Agency of Canada. Please see the original document for a complete list of recommendations on this topic.

Purpose: 

Give health care providers evidence-based information on safe sleeping practices and SIDS prevention in infants, so that they can provide caregivers with accurate and consistent advice.

Definition: 

Sudden Infant Death Syndrome (SIDS) is the sudden and unexpected death of an infant younger than 1 year old. In these cases, there is no obvious cause of death despite thorough investigation including clinical history, autopsy, and death scene investigation.

Epidemiology:

• SIDS can occur anytime between the ages of 0-1 year
• More common between 2-4 months of age
• Risk decreases after 6 months of age

Etiology: 

• Exact cause of SIDS is unknown
• Currently, it is considered a complex multifactorial disorder
• SIDS is thought to arise from interaction between certain genetic, metabolic, and environmental factors

Risk factors: 

• Non-modifiable: male, premature, low birth weight, Aboriginal heritage, socioeconomically disadvantaged background
• Modifiable: sleeping prone, maternal smoking during pregnancy
• Risk factors for both SIDS and unintentional suffocation while sleeping:
  • Sleeping surface shared with another person
  • Presence of soft bedding

Prevention: Based on the modifiable risk factors listed above, the following recommendations have been made to prevent SIDS and promote safe sleeping practices:

• Limit exposure to tobacco smoke before and after birth
• Encourage room sharing
  • During the first 6 months of life (when SIDS risk is highest) infants should sleep in the same room as their caregivers
  • It is important to differentiate between room sharing and bed sharing
  • Bed sharing is where the infant sleeps on the same surface as another person
    • It is linked to SIDS and unintentional death from entrapment, overheating, overlaying, and suffocation, and therefore is strongly discouraged
• Create an appropriate sleeping environment  for the infant
  • Infants should have their own bassinet, crib or cradle that meets current safety regulations
  • Only a firm mattress and fitted sheet are needed
  • Extra items such as bumper pads and other bedding actually pose a suffocation risk
  • Have the infant sleep in one-piece sleepwear. Avoid excess clothing or blankets which could cause them to overheat
• Always place infants on their back to sleep
  • Sleep positioning devices should not be used to keep infants supine as there is a possibility of suffocation
  • Encourage tummy time during the day. It helps strengthen muscles and can prevent plagiocephaly from back sleeping
• Breastfeed infants
  • Any amount of breastfeeding protects against SIDS, but exclusive breastfeeding is most beneficial
  • Pacifiers also seem to reduce the risk of SIDS

References: 

Public Health Agency of Canada. (2011). Joint statement on safe sleep: Preventing sudden infant deaths in Canada. Retrieved from: http://www.phac-aspc.gc.ca/hp-ps/dca-dea/stages-etapes/childhood-enfance...