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research paper

Indian Pediatr 2015;52: 669-673

Normative Blood Pressure Data for Indian Neonates

Moumita Samanta, Rakesh Mondal, Somosri Ray, Tapas Sabui, *Avijit Hazra, #Chanchal Kundu, Debolina Sarkar and Dibyendu Roychowdhury

From Departments of Pediatric Medicine, Medical College Kolkata; #Cardiology, *Pharmacology, IPGME&R and SSKM Hospital; Kolkata, West Bengal, India.

Correspondence to: Dr Rakesh Mondal, Balarampur, Mahestala, Kolkata 700141, West Bengal, India.
Email: [email protected]

Received: September 01, 2014;
Initial review: January 02, 2015;
Accepted: May 29, 2015.



Objective: To establish the normative blood pressure (BP) values in healthy Indian neonates using oscillometric method, and to develop BP percentile charts.

Design: Prospective observational study.

Setting: Neonatal unit of a teaching hospital in Eastern India.

Participants: 1617 hemodynamically stable inborn neonates without birth asphyxia, major congenital anomaly, maternal complications (e.g. preeclampsia, hypertension, diabetes) or critical neonatal illness.

Procedure: Quite state measurements of systolic BP (SBP), diastolic BP (DBP) and mean arterial pressure (MAP) were recorded by oscillometric method on day 4, 7 and 14 of postnatal life. The averages of three readings at 2-minute intervals were used.

Results: Percentile charts (providing 5th, 10th, 25th, 50th, 75th, 95th, and 99th percentile values) have been developed. SBP, DBP and MAP showed a steady rise from day 4 to day 14, and were comparable between males and females, but were significantly lower in preterms than in term neonates

Conclusions: Normative neonatal BP data along with gestational age-wise percentile charts shall be of help for decision-making and planning for sick newborns.

Keywords: Blood pressure, Hypertension, Neonate, Normogram.


Neonatal hypotension and hypertension require early detection and timely management due to possible association with short and long term adverse outcomes [1]. Blood pressure (BP) increases with birth weight, and gestational and chronological age [2]. However, there is paucity of studies documenting normative blood pressure values in healthy term and preterm neonates in India. Invasive BP monitoring, even though more accurate; is associated with complications such as infection, vasospasm and thrombus formation [3-5]. Indirect methods have been shown to be reliable and consistent if conducted under standardized conditions [6]. Studies evaluating normal BP ranges for normal, low birth weight (LBW) and very low birth weight (VLBW) infants have drawbacks of small sample size, retrospective data collection, infrequent measurements, or inclusion of infants on inotropes or with cerebral injury [1,7,8]. We planned this study to generate normative BP　readings of healthy Indian neonates.

Methods

This prospective observational study was conducted on healthy term and preterm newborns delivered in a teaching hospital from September 2013 to April 2014 in Kolkata, India. The study protocol was approved by the Institutional Ethics Committee.

Enrolment was done on 3 days in a week (Monday, Wednesday and Friday). All healthy newborns were enrolled after birth on the scheduled days after obtaining written informed consent from the parent. Exclusion criteria included birth asphyxia; infants of mothers with hypertension, preeclampsia, gestational diabetes, type 1 diabetes mellitus or illicit substance use;　major congenital anomaly; and sepsis or other problems requiring admission to neonatal intensive care unit (NICU), except for those preterm neonates admitted only for establishment of feeding. Each neonate was studied on day 4, 7, and 14 of birth. If discharged prior to day 14, the mother was asked to come for follow-up on the scheduled day.

Multichannel monitor (Larson and Turbo make; Star 55) was used to determine systolic BP (SBP), diastolic BP (DBP), and mean arterial pressure (MAP) by oscillometric method. Disposable infant BP cuffs (sizes 6-11 cm, 4-6 cm and 1-4 cm) were used. The smallest cuff size that covered at least two- thirds of the right upper arm length and encompassed the entire arm circumference was selected. One investigator performed all BP measurements using a standardized protocol [9]. The appropriate-sized cuff was applied to the right upper arm with baby in prone position. Three successive BP recordings were taken at 2-minute intervals. The average of these three readings, rounded off to the nearest mmHg, was calculated and recorded for further analysis. The tasks of feeding the babies, applying an appropriate BP cuff and keeping them in prone position were done by the trained nursing staff. The doctor was involved in checking the preparatory work and recording the BP. Mean, standard deviation (SD),95% confidence interval (CI), and 5th, 10th, 25th, 50th, 75th, 95th and 99th percentile values were calculated for the whole group. Statistica version 6 (Tulsa, Oklahoma: StatSoft Inc., 2001) and MedCalc version 11.6 (Mariakerke, Belgium: MedCalc Software 2011) softwares were used for statistical analysis.

Results

From the 2055 neonates screened, data of 1617 (916 males) were available for analysis. Fig. 1 shows the flow chart for the study participants. Of the 1617 analyzed, 97 had some missing data (86 babies present on day 7 but absent on day 14; 11 absent on day 7 but present on day 14). There were 1427 term (1412 appropriate for gestational age [AGA]) and 190 preterm (186 AGA) newborns. The of BP recordings on days 4, 7 and 14 for term and preterm neonates have been presented in Table I along with the percentile values on the respective days. There were no statistically significant difference in mean SBP, DBP and MAP recordings between males and females. However, all three parameters were significantly lower in preterms compared to term neonates on each of the three days. 

TABLE I  Oscillometric Neonatal Blood Pressure (mmHg)  Stratified by Gestational  Status (N=1617)
Parameter Status Mean (SD) 5th 10th 25th 50th 75th 90th 95th 99th
Day 4-SBP Term 74 (7) 62 64 68 74 78 82 84 88
Preterm 62 (7) 46 54 58 62 66 72 74 78
  DBP  Term 54 (7) 42 43 50 54 60 62 62 66
Preterm 43 (6) 32 34 40 42 47 50 52 56
  MAP Term 61 (6) 48 50 56 60 66 68 70 73
Preterm 49 (6) 38 41 46 48 53 56 58 62
Day 7-SBP Term 78 (6) 66 70 74 78 82 84 87 90
Preterm 66 (7) 54 58 62 66 70 74 77 82
  DBP Term 58 (6) 50 50 55 60 62 64 66 72
Preterm 47 (6) 38 40 42 48 50 55 56 62
  MAP Term 64 (5) 54 56 61 66 68 70 72 75
Preterm 53 (5) 44 46 50 54 57 60 63 66
Day 14-SBP Term 81 (5) 72 74 78 82 84 88 90 90
Preterm 70 (7) 60 61 66 70 75 78 80 85
  DBP Term 61 (6) 52 54 60 60 64 68 70 74
Preterm 51 (6) 40 42 50 50 55 60 60 62
  MAP Term 68 (5) 58 61 66 68 71 74 75 79
Preterm 58 (6) 47 49 56 57 61 66 66 68
SBP = Systolic blood pressure;  DBP = Diastolic blood pressure;  MAP = Mean arterial pressure. 
 

 

Fig. 1 Flow chart for the study participants.

Table II presents BP data for days 4, 7 and 14 by gestational age, from 32nd to 40th week. 

TABLE II Oscillometric Neonatal Blood Pressure Recordings Stratified by Gestational Age (Weeks) at Birth
Week BP Day-4 Day-7 Day-14
Percentile SBP DBP MAP SBP DBP MAP SBP DBP MAP
32 10 50 32 41 55 40 45 60 40 48
50 58 40 46 62 42 50 68 50 56
90 68 50 54 72 52 59 75 55 61
95 77 50 56 74 55 59 75 56 62
99 78 56 58 74 56 61 76 58 64
33 10 54 35 43 61 40 48 62 42 49
50 64 42 48 68 45 52 68 50 56
90 74 51 56 74 52 59 78 58 64
95 77 52 56 78 55 60 78 58 64
99 82 58 66 80 60 66 82 58 66
34 10 55 30 41 60 40 48 62 44 50
50 62 42 48 65 48 53 68 50 56
90 70 48 53 72 52 58 76 55 62
95 78 50 56 74 54 59 78 58 64
99 78 55 61 78 58 64 82 60 67
35 10 59 38 45 62 42 50 68 48 55
50 64 44 50 68 50 56 73 52 59
90 69 51 56 74 54 60 78 58 64
95 72 52 56 76 55 61 78 60 66
99 74 58 62 78 62 66 78 62 67
36 10 55 40 46 62 42 50 65 50 56
50 66 44 51 68 50 57 74 55 60
90 75 52 59 78 56 63 80 62 66
95 76 55 61 78 58 64 82 62 68
99 77 55 62 82 62 66 86 65 68
37 10 62 42 49 68 50 56 74 52 60
50 72 52 58 76 56 62 78 60 66
90 80 60 66 82 62 68 88 62 69
95 82 62 66 85 62 68 88 68 73
99 84 64 70 87 68 74 90 72 77
38 10 64 47 53 70 52 58 74 54 61
50 73 53 60 78 58 65 80 60 67
90 79 62 66 84 62 69 86 66 72
95 82 62 67 84 64 70 88 68 74
99 84 66 72 88 68 74 90 72 76
39 10 66 44 51 70 50 58 74 55 61
50 76 54 61 78 60 66 82 60 68
90 82 62 67 84 62 69 88 68 73
95 84 62 68 86 66 72 90 70 75
99 88 66 72 90 72 74 92 75 80
40 10 68 50 56 72 53 60 78 58 64
50 77 58 64 82 60 68 84 64 70
90 84 62 70 87 66 72 90 70 75
95 87 64 70 88 68 74 90 70 76
99 88 68 74 90 72 77 90 76 81

Discussion

These gestational age-wise percentile charts for Indian newborns are likely to be of help in NICU settings for bedside decision-making, and for management of sick neonates. The limitations of the study include small sample size for preterm and SGA neonates. All the recordings were done by a single observer. Although single observer eliminates the possibility of interobserver variation, it increases the chances of erroneous result if this observer keeps on making a systematic error.

In our study, the median values of SBP, DBP and MAP on day 4 of life were comparable to those found by Kent, et al. [10] in Australian term newborns. The day-wise increment in MAP as seen in our study was also reported by Cunningham, et al. [11]. Kent, et al. [12] in 2009 reported normative BP data in 147 non-ventilated preterm neonates, and showed that the BP in preterm neonates was comparable to that of term infants, after two weeks. However, analysis of data from 566 preterm neonates in southern Cleveland [13] showed that BP is preterms continues to rise after 10 days of life, and stabilizes by a postconceptional age of 44-48 weeks. A higher value of DBP recorded in our study could be possibly due to the influence of higher rates of vaginal delivery, intrauterine growth retardation and maternal steroid injections, which were taken into consideration [14-16]. Higher DBP at the end of 2nd week with drop in DBP in the subsequent weeks has been reported earlier [17]. Follow-up blood pressure data in these neonates was not collected.

We conclude that the data derived from this study can be used to diagnose hypotension and hypertension in Indian newborns and monitor blood pressure of sick neonates.

Contributors: MS, SR, RM, DS, TS, DRC: diagnosis and management of the patients; RM, MS, CK, TS: searched the literature; RM, MS, AH: drafted the manuscript; MS, CK, AH, RM: critical review. All the authors approved the final version.

Funding: None; Competing interests: None stated.


What is Already Known?

• Normal blood pressure data for neonates are available from other countries.

What This Study Adds?

• Normative blood pressure data with gestational age-wise percentile charts from Indian newborns is provided.

References

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