Continuing Nursing Education

Continuing Nursing Education
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What Is ‘Normal?’ Evaluating Vital Signs
Debra Van Kuiken, Myra Martz Huth
ital signs (VS) are indicators
of physiological functioning and include temperature, respiratory rate, heart
rate (pulse), and blood pressure (BP).
Health care professionals measure VS
to assess, monitor, evaluate, and document an individual’s physiological
status or change in condition (Royal
College of Nursing, 2011). Depending
on the individual’s condition, VS are
monitored and recorded routinely by
policy, tradition, or expert opinion,
whether needed or not (Evans,
Hodgkinson, & Berry, 2001; Zeitz &
McCutcheon, 2006). Five years ago,
pediatric nurse leaders and evidencebased practice (EBP) experts from children’s hospitals across the country
voiced concerns about the frequency
of VS at a National Summit for
Pediatric and Adolescent EvidenceBased Practice (Melnyk et al., 2007).
This summit resulted in our team formulating a clinical question, searching for the evidence, critically appraising the evidence, and formulating
conclusions on normal parameters.
Before the question on the frequency of VS could be addressed, two
fundamental questions needed exploration, and thus, became the focus of
our work. The questions are:
Among pediatric patient ages 1
through 5 years, what are “normal” VS parameters?
Among pediatric patient ages 1
through 5 years, what is a significant clinical change in VS?
The purpose of this systematic
review was to determine the best evidence for normative parameters for
VS in healthy children 1 to 5 years of
age and what constituted a clinically
significant change in VS in hospitalized, but otherwise healthy, children.
Debra Van Kuiken, PhD, RN, is an Assistant
Professor, Xavier University, Cincinnati, OH.
Myra Martz Huth, PhD, RN, FAAN, is an
Associate Professor, Alverno College, JoAnn
McGrath School of Nursing, Milwaukee, WI.
Problem: Vital sign (VS) assessment and monitoring are often routinely scheduled whether they are needed or not. This practice led pediatric nurse leaders to
voice concerns about the frequency of VS at a National Summit for Pediatric and
Adolescent Evidence-Based Practice. A search of databases yielded no direct
evidence regarding frequency. However, we determined that before this question
could be adequately addressed, we first needed answers to two other important
questions concerning normative values for this population and what constitutes
significant change in VS.
Clinical Questions: Among pediatric patients 1 to 5 years of age, 1) what are
“normal” VS parameters, and 2) what is a significant change in VS?
Method: Additional searches, including a hand search, yielded five systematic
reviews, one case-control study, five descriptive studies, and eight textbooks on
normative values for children. Additionally, six articles on pediatric early warning
signs (PEWS) were also reviewed.
Findings: Systematic reviews agree that vital signs are ill-defined and are a poor
indicator of physical deterioration in young children. Normative VS tables are
inconsistent and sometimes contradictory. Change parameters in the PEWS literature also lacked consistency. There is scarcity of high-quality, consistent
research on normative VS values for children. Additionally, there is a lack of evidence to guide the frequency of assessments and use of behavioral and physiologic indicators of decline in young hospitalized children. This points to opportunities for further research in these areas. Clinicians need VS guidelines based
on research to guide their clinical decision making and interventions.
Literature searches using keywords “vital signs,” ”blood pressure,”
“heart rate,” “respiratory rate,” “normal,” “normative,” “early warning,”
“deterioration,” “pediatric,” and “children” were run using the EBSCO,
CINAHL, PubMed, and Scopus databases. Additionally, authors performed
manual searches of references, guidelines, and textbooks. Articles and texts
were excluded if they did not address
children 1 to 5 years of age, or if they
addressed a specific disease or illness
process, such as cardiovascular disease
or asthma. Eight textbooks and four
review articles containing pediatric
normative VS parameters were reviewed. The search revealed nine articles
reporting research findings on one or
more parameters. In addition, six articles about pediatric early warning
parameters were also reviewed. Although literature on temperature and
oxygen saturation was found, only
those results pertaining to BP, pulse,
and respiratory rates are reported here.
Evidence was then rated based on
the system proposed by Melnyk and
Fineout-Overholt (2011). In this rating
system, Level I is the highest ranked
and includes a systematic review or
meta-analysis. Level II, consists of randomized controlled trials, while Level
III lacks the randomization of the previous level. Case-control and cohort
studies comprise Level IV, and a systematic review from descriptive studies is rated as Level V. Level VI is based
on evidence from one descriptive or
qualitative study. The lowest level of
evidence is Level VII; which is classified as expert opinion from individuals or committees.
Review of the Literature
Nursing and medical textbooks
often provide tables with normative
data for VS; however, the tables were
not consistent across texts. Although
parameter ranges overlapped and were
similar, some differences were notable.
PEDIATRIC NURSING/September-October 2013/Vol. 39/No. 5
For instance, for children 3 years of
age, Bowden and Greenberg (2008)
listed a normal heart rate (HR) range
for children 3 to 4 years of age as 80
to 120 beats/minute, whereas Van
Hare and Dubin (2001) grouped 3year-olds with younger counterparts
and listed 89 to 152 beats/minute to
be the normative HR range. Several
nursing textbooks reproduced a table
from a medical textbook that displayed HR ranges dependent of age
and wakefulness (Gillette et al., 1989).
However, Gillette et al. (1989) cited
only a 1981 study that found 65% of
healthy 7- to 11-year-olds (N = 104)
experience sinus pauses and heart
rates below 45 to 55 beats/minute
during the night hours when monitored over 24 hours (Southall,
Johnston, Shinebourne, & Johnston,
1981). Other than this reference in
Gillette et al. (1989), all other textbooks cited other textbooks for HR or
respiratory rate normative data.
When presenting BP normative
charts, textbooks refer to or reproduce
the Fourth Report on High Blood
Pressure in Children and Adolescents.
The Fourth Report was developed
from previously obtained datasets
(National High Blood Pressure Education Program [NHBPEP] Working
Group on High Blood Pressure in
Children and Adolescents, 2004). This
report presents the values for the
50th, 90th, 95th, and 99th percentiles
for systolic BP (SBP) and diastolic BP
(DBP) based on gender, age in years,
and height percentiles, yielding a
complex table of 1,904 values. The
primary purpose of this report was “to
provide recommendations for diagnosis, evaluation, and treatment of
hypertension based on available evidence” (NHBPEP Working Group on
High Blood Pressure in Children and
Adolescents, 2004, p. 555). The
Fourth Report defines pre-hypertension and hypertension based on the
90th and 95th percentile respectively
(NHBPEP Working Group on High
Blood Pressure in Children and Adolescents, 2004). Yet, many values for the
90th percentile fall above the 120/80
adult guidelines for hypertension
(Kaelber & Pickett, 2009; Krishna,
PrasannaKumar, Desai, & Thennarasu,
2006). Kaelber and Pickett (2009)
have proposed a simplified table
based on age and gender only, but
again, the purpose is aimed at identifying children needing further attention regarding hypertension and do
not provide minimum BP values.
While these tables are based on a large
dataset, the lack of control in the procedures of obtaining the data is a limitation.
One series of nursing textbooks
(Hockenberry & Wilson, 2011; Wilson
& Hockenberry, 2012) cite Park and
Menard (1989) for normative oscillometric BP tables for infants through 5
years of age. Park and Menard (1989)
showed that oscillometric BP readings
were higher than those obtained by
auscultation. Again, these textbook
tables are indicated for diagnosis of
hypertension versus full normative
ranges for these ages.
Research Establishing
Normative Parameters
After this review of a sample of
nursing and medical textbooks, the
authors concluded that there was a
lack of consistency across textbooks
in the presentation of normative values for VS. Additionally, the given
normative values lacked reference to
empirical data. Although BP charts
cited research, the authors questioned
using guidance on hypertension for
purposes of determining normative
values in the acute setting. The following is a review of recent research
into determining normative values.
Tables 1 to 3 give additional information on these studies. Not all studies
produced normal ranges of values.
Studies on respiratory rates
(RR) in children. The need for reference ranges prompted researchers in
Italy to assess RR in healthy infants
and young children (see Table 1)
(Rusconi et al., 1994). Researchers
measured RR by direct placement of
stethoscope on the bare chest for 60
seconds. Rusconi et al. (1994) found
evidence of significant difference in
RR between awake and sleeping conditions. Further, RR measured by auscultation were significantly higher
than by observation only in both
awake and sleeping conditions
(Rusconi et al., 1994). These findings
are presented as smooth centile
curves rather than as normal range of
Wallis and associates completed
two descriptive studies out of the
United Kingdom and South Africa
(Wallis, Healy, Undy, & Maconochie,
2005; Wallis & Maconochie, 2006).
Both studies assessed fully clothed
school children after 10 minutes of
sitting. Researchers observed chest
wall movement for 60-second observation. The authors maintained that
PEDIATRIC NURSING/September-October 2013/Vol. 39/No. 5
this method of observation decreases
child’s awareness as compared to a
pneumogram or auscultation. Although researchers were explicit in
counting partial breaths as full
breaths, these articles refer to only
one 60-second period being observed,
and there is no reference to inter-rater
reliability. The possibility of measurement error is a limitation to these
studies, and therefore, do not give
strong evidence of the normal distribution of respiratory rates.
In a meta-analysis of 69 studies
reporting on respiratory rates and
heart rates in children from birth to
18 years of age, Fleming et al. (2011)
calculated RR and HR centiles.
Methods of measuring RR were
reported as primarily manual; however, manual was not defined. Smooth
curve graphs are presented showing
the decrease in RR as the child ages,
but normal range of rates are not
Studies on heart rates (HR) in
children. Studies aimed at determining normative HR in children have
differed in the method of measurement and in the length of observation. Two studies by Wallis and associates also looked at defining the
distribution of HR in healthy children
(Wallis et al., 2005; Wallis &
Maconochie, 2006). The procedures
used a finger probe monitor for
obtaining HR. The authors provided
rationale using a finger probe, stating
there was no evidence to suggest that
HR would be altered by the presence
of the probe (Wallis et al., 2005).
However, the authors do not explain
the reason for averaging the five-second intervals over a 60-second span.
Both HR and RR normative ranges
were derived from statistical transformations due to skewed distributions.
These authors define normative HR
and RR ranges by age based on the 2.5
and 97.5 percentile values from these
samples (see Table 2).
Other studies have used 24-hour
electrocardiogram (ECG) monitors to
gather HR data. Massin, Bourguignont,
and Gerard (2005) compared the HR
and rhythms of healthy ambulatory
children with hospitalized children.
These authors provided data on minimum, maximum, and mean HR for
groups; however, children 1 to 5 years
of age were presented as one group.
Another descriptive study of 616 children from birth to 20 years of age
used Holter monitor recordings to
establish age- and gender-based “lim217
What Is ‘Normal?’ Evaluating Vital Signs
Table 1.
Research Studies on Normative Respiratory Rates in Children 1 to 5 Years of Age
Author, Date,
Design, Purpose Sample Description
Level of
Respiratory Rate
Rosconi et al.
(1994); Italy
testing for
stability across
time, method of
measure, and
sleep status
Purpose: To
reference values
for RR
N = 618; ages 15
months to 3 years
old, no respiratory
illness or severe
disease or
n = 309; daycare
n = 309; inpatient
and outpatient
Stethoscope placed
on bare chest and
measured for 60
50 children were
measured twice 30
to 60 minutes apart
with stethoscope
50 children
assessed by
auscultation and
observation by 2
Findings provided as smoothed
centile curves for awake/calm
and for asleep children by age
• No specific recommendations
Repeatability over time: 95%
RR by stethoscope significantly
higher than by observation.
• 2.6 breaths/min when awake
(p = 0.015)
• 1.8 breaths/min when asleep
(p < 0.001)
Difference between awake/calm
and asleep was significant
(p < .001) when controlling for
gender, season, or setting
Wallis et al.
(2005); United
Determine HR
and RR
reference values
N = 1,109 school
children (4 to 16
years old) in quiet
schoolroom setting;
31% response rate;
n = 49; 4-year-olds
n = 69; 5-year-olds
RR: 60 seconds of
observation of
clothed chest wall
after 10 minutes of
sitting quietly
Normal range defined by
2.5 and 97.5 percentiles
Wallis &
(2006); South
replicated Wallis
et al. (2005)
Compare sample
to reference
range established
with Wallis et al.
(2005) study
N = 346 children
(5 to 16 years old)
Setting: School
RR: 60 seconds of
observation of
clothed chest wall
after 10 minutes of
sitting quietly
Ranges given in box plot form
Median RR (age 5) =
22 beats/minute
Fleming et al.
(2011); United
evidence for
reference ranges
69 studies
N = 143,346 healthy
Data extraction
included setting,
method, awake/
asleep, and age
If multiple
readings per group,
metaanalysis used
awake, baseline,
least invasive
Centiles (1st, 10th, 25th, 50th,
75th, 90th, 99th) presented as
Authors report differences found
compared to accepted pediatric
life support guidelines
4 years
5 years
20 to 26
19 to 25
Notes: HR = heart rate, RR = respiratory rate.
its” (Salameh et al., 2008). Authors
reported mean minimum HR and
mean HR by age group; again children 1 to 5 years of age were presented as one group. No maximum HR
was reported because activity was not
controlled, and therefore, no “normative” ranges were given.
Other factors may influence HR
in children. Fleming et al. (2011)
identified several factors that influ218
ence HR in children. In addition to
the setting and methods of measurement, their review also found the
level of development of the country
and year of the study to be factors in
children’s HR.
Racial, ethnic, and gender disparities were also found. A descriptive
study found African-American children 6 to 11 years of age had significantly higher HR (p < 0.001) during
sleep than Caucasian and Hispanic
children when body mass indices
(BMIs) were equal (Archbold, Johnson,
Goodwin, Rosen, & Quan, 2010). This
study also found that girls had sleeping HRs near 3.5 beats/minute faster
than boys.
Studies on blood pressure in
children. As noted earlier, the most
cited information on BP norms is
from the Fourth Report. Current BP
PEDIATRIC NURSING/September-October 2013/Vol. 39/No. 5
Table 2.
Research Studies on Normative Heart Rate in Children 1 to 5 Years of Age
Author, Date,
Design, Purpose Sample Description
Level of
Heart Rate
Wallis et al.
(2005); United
HR and RR
reference values
N = 1,109 school
children (4 to 16
years old) in quiet
schoolroom setting
31% response rate;
n = 49; 4-year-olds
n = 69; 5-year-olds
HR: 60 seconds
with DatexS5 Lite
monitor with finger
Analysis: Mean of
5 second intervals
Wallis &
(2006); South
replicated Wallis
et al. (2005)
To compare
this sample to
reference range
established with
Wallis et al.,
2005 study
N = 346 children
(5 to 16 years old)
Setting: School
HR: 60 seconds
with DatexS5 Lite
monitor with finger
Analysis: Mean of
5-second intervals
No significant difference between
South African and UK sample
(Wallis et al., 2005)
HR ranges given in box plot form
Median HR (age 5) =
91 beats/minute
Salameh et al.
Evaluation of HR
variability and
establish age and
gender HR limits
for children 0 to
20 years old
N = 616 outpatient
children; all subject
were ruled out for
cardiac or thyroid
Holter monitors with
analysis on Mars
8000; RR intervals
calculated for HR
HR correlated to age using
non-linear regression;
R2 = 0.66 to 0.78; p < 0.0001
Gender differences found after
age 10
Age greater than 1 to 5 years
4 years
5 years
81 to 131
74 to 121
HR: M (SD) Males Females
Minimum HR 63 (9) 63 (11)
Mean HR
109 (14) 108 (15)
No maximum HR given
Massin et al.
(2005); Belgium study of
ambulatory and
differences in
HR and rhythms
Fleming et al.
(2011); United
Purpose: to
RR and HR
reference ranges
N = 376 (ages birth
to 16 years old)
n = 264 healthy
ambulatory children
n = 112 hospitalized
Analysis grouped
1- to 5-year-olds
in one group
Holter monitor
MR45 Oxford with
2 channel tape
Analysis with
Medilog Excel 2.0
Self-report diaries
recording activities
and times kept by
In the age group of 1 to 5 years
• No difference in HR between
ambulatory (AMB) and
hospitalized (HOSP) children
• Supraventricular and
ventricular contractions were
common in both groups
For 1 to 5 year olds
69 studies
N = 143,346 healthy
Data extraction
included setting,
method, awake/
asleep and age
If multiple
readings per group,
metaanalysis used
awake, baseline,
least invasive
Centiles (1st, 10th, 25th, 50th,
75th, 90th, 99th) presented as
Authors report differences found
compared to accepted pediatric
life support guidelines
Significant predictors of HR include:
• Setting (community higher)
• Method (automated higher)
• Country (developing higher)
• Wakefulness (awake higher)
• Year (older studies lower)
Minimum HR 61 ± 9 60 ± 8
Maximum HR 180 ± 14 174 ± 18
Notes: HR = heart rate, RR = respiratory rate.
PEDIATRIC NURSING/September-October 2013/Vol. 39/No. 5
What Is ‘Normal?’ Evaluating Vital Signs
Table 3.
Research Studies on Normative and High Blood Pressure in Children 1 to 5 Years of Age
Author, Date,
Design, Purpose Sample Description
Level of
Blood Pressure – Higher Limits
National High
Blood Pressure
Working Group
(2004); United
Purpose: Update
tables reporting
distribution for the
diagnosis of prehypertension and
Park, Menard,
& Schoolfield
(2005); United
N = 7,208
schoolchildren, ages
5 to 17 years old
BP tables for
Dinemappobtained BP;
relationship of BP
to age, gender,
weight, height
Dinemapp SBP
readings 8 to 12
mmHg higher than
Dinemapp DBP
readings 4 to 5
mmHg higher than
K5 ausculatory
Develop a
simplified table
for identifying
high blood
Used lower limit of
height (less than 5th
percentile) and the
abnormal (greater
than 90th percentile)
blood pressure for
ages 3 to 17 years
by gender
Used recommended
cutoff of SBP greater
than or equal to 120
and DBP greater
than or equal to 80
Kaelber &
Pickett (2009);
United States
Haque &
Zaritsky (2007); secondary
United States
Extrapolate 5th
percentile values
for identifying
11 studies from the
United States
N = 63,227, ages
1 to 17 years old
Blood pressure data
from previous
Note: Authors
recommend to have
child seated for 5
minutes, use of
correct cuff size,
auscultation method
with 5th Korotkoff
sound for DBP
Data from
The Fourth Report
on Diagnosis,
Evaluation and
Treatment of High
Blood Pressure
in Children and
Adolescents (2004)
Data from 1987
Task Force reports
on Hypertension.
N > 63,000;
Children ages
1 to 17 years old.
Update BP distribution tables by
gender, age, and height to
include 50th, 90th, 95th, and 99th
Yielding 56 values for each age
(year) for SBP and DBP each or
a table of 1,904 values
Normal BP: defined as the lesser
of less than 90th percentile or
less than 120/80
Blood pressure by gender and
percentile for 5 year olds
Weight is better predictor of BP
than is height
Blood pressures needing further
evaluation for pre-hypertension
Age is represented in years
Extrapolation from
Table for 5th percentile of SBP by
height percentile and age and
gender yielding 170 values
Assumed normal
distribution of
SBP at 5th percentile ranges
original data and
that difference in
62 to 72
66 to 73
pressure between
67 to 74
68 to 73
95th and 50th
percentile was equal
68 to 77
68 to 76
to difference
70 to 79
71 to 76
between 5th and
72 to 80
71 to 79
50th percentile
Age is represented in years
Data believed to be
from ausculatory
Notes: BP = blood pressure, DBP = diastolic blood pressure, SBP - systolic blood pressure.
PEDIATRIC NURSING/September-October 2013/Vol. 39/No. 5
nomograms are presented to account
for age, gender, and height percentiles
simultaneously (NHBPEP Working
Group on High Blood Pressure in
Children and Adolescents, 2004).
Before 1993, BP tables were presented
accounting for age and gender only,
but prior research suggested physical
maturity (vs. chronologic age) is the
primary indicator of BP (Gillum,
Prineas, & Horibe, 1982). In 1993,
Rosner, Prineas, Loggie, and Daniels
proposed that weight was not appropriate for accounting for maturity
because the inclusion of obese children in the sample might lead to
“normal” values that were unhealthy.
Researchers in the United Kingdom
found weight was a stronger predictor
of normative BP than height when
adjusting for age and gender in a sample of children and young adults
ranging in age from 4 to 24 years (N =
22,901) (Jackson, Thalange, & Cole,
2007). They found that systolic blood
pressure (SBP) and diastolic blood
pressure (DBP) rose with age, but
there was a marked increase at puberty with boys, which may have been
linked with increase of weight at male
puberty. Jackson et al. (2007) also
redefined high BP at the 98th percentiles and high-normal between the
91st and 98th percentiles.
The issue of weight or BMI to
predict higher BP, both systolic and
diastolic, has been examined in the
United States and China. Falkner and
associates (2006) did a retrospective
chart review of 18,618 children 2 to
19 years of age from pediatric primary care sites. BMI was a strong predictor of BP, even in children 2 to 5
years of age (n = 6331). Other predictors of BP were age, height, insurance
type, and gender. In a sample of
208,513 young Chinese children
approximately one month to 7 years
of age, researchers compared obese
with non-obese children (He, Ding,
Fong, & Karlberg, 2000). Differences
in SBP and DBP between groups
became significant at 3 years of age
for both girls and boys.
Normative values for VS have been
based on percentiles in the distribution
of data from epidemiologic surveys.
With evidence that weight and BMI
factor into an increase in BP, Rosner,
Cook, Portman, Daniels, and Falkner
(2008) cautioned against adjusting normative values based on sampling that
may include obese children.
Other factors in determining
BP limits. Several studies gathering
data on national normative BP values
have been reported from countries as
diverse as India and Saudi Arabia (Al
Salloum, El Mouzan, Al Herbish, Al
Omar, & Qurashi, 2009; Krishna et al.,
2006). Krishna and colleagues (2006)
eliminated both undernourished and
obese children from the sample.
Although there was no attempt to statistically compare values for Indian
children to their American counterparts, Indian values for children 3 to 5
years of age were higher than those in
the Fourth Report. The study from
Saudi Arabia compared Saudi 90th
percentile values to those of Turkish
and American children and found a
variance among the three samples (Al
Salloum et al., 2009). A study in the
United States compared rates of elevated BP between ethnic groups
(White, Black, or Hispanic, by selfreport) in U.S. children (Rosner et al.,
2009). This secondary analysis of the
data set from the Fourth Report (n =
58,698) found that adjusting for BMI,
Hispanic boys were more likely to
have hypertension than were White
boys (OR 1.21, p = 0.002), while Black
boys were more likely to be prehypertensive than White boys (OR 1.32, p <
0.001). Girls did not have any differences between groups in hypertension after adjusting for BMI; however,
Black girls were more likely to have
prehypertension than White girls (OR
1.23, p < 0.001) and Hispanic girls
were less likely to be prehypertensive
compared to White girls (OR = 0.80, p
= 0.01).
Studies have raised questions
regarding diurnal changes and differences in method of obtaining BP.
Lurbe and associates (1996) obtained
24 hours of ambulatory and conventional (oscillatory) BP reading on 228
normotensive children 6 to 16 years
of age. The children were instructed
to avoid vigorous physical activity
while being monitored. Comparing
average daytime BP between 0800
and 2000 to nighttime average measures taken between 2400 and 0600,
Lurbe et al. (1996) found an average
drop in SBP of 12.6 ± 6.7 in boys and
11.4 ± 5.7 in girls at night. DBP also
dropped an average of 14.2 ± 5.9
(boys and girls combined). These significant nocturnal drops in BP were
recorded in more than 80% of the
children in the first phase of the
study. However, the diurnal curve of
BP parameters was not reproducible
in a subsample of 31 children (Lurbe
et al., 1996).
PEDIATRIC NURSING/September-October 2013/Vol. 39/No. 5
A difference between methods of
BP measurement was also found significant. Several studies have pointed
to BP measured by oscillatory were
higher than those measured with ausculatory means (Lurbe et al., 1996;
Midgley, Wardhaugh, Macfarlane,
Magowan, & Kelnar, 2009; Park,
Menard, & Schoolfield, 2005). Park et
al. (2005) caution about false diagnoses of hypertension if the Fourth
Report charts are used to evaluate BPs
obtained with an oscillatory method.
These studies point to the lack of
agreement on what are considered
“normal” values for BP in children
and the variations due to method of
measurement. A weakness in many
studies is the possible variance and
measurement error due to protocol
around the data collection and factors, such as cuff size, position of the
child, and techniques of taking a
Defining lower limits of BP.
Haque and Zaritsky (2007) further
explored data from the NHBPEP to
develop tables for hypotension as
defined by values that fall below the
5th percentile. These authors used the
given values for the 50th and 95th
percentiles, with the assumption of
normal distribution, to calculate the
values for 5th percentile based on
gender, age, and height percentile.
This work was not intended for use as
normative data.
The literature on early warning
tools was reviewed to determine what
was known about significant change
in VS parameters. Pediatric early
warning tools have been developed in
an effort to better predict deterioration and provide care that is timely.
There were multiple tools identified
in the literature (Duncan, Hutchison,
& Parshuram, 2006; Edwards, Powell,
Mason, & Oliver, 2009; Egdell, Finlay,
& Pedley, 2008; Haines, Perrott, & Weir,
2006; Monaghan, 2005; Parshuram,
Hutchison, & Middaugh, 2009). These
tools include varying parameters to
assess deterioration of a child. The
Brighton Paediatric Early Warning
Score measures deterioration on three
items of behavior, and cardiovascular
and respiratory changes (Monaghan,
2005). For example, the respiratory
item gives one point for more than 10
breaths per minute over the normal
rate, two points for more than 20
above normal, and three points for
five below the normal respiratory
rate. Although HR and RR are included in the items for this tool, there is
What Is ‘Normal?’ Evaluating Vital Signs
little information on how these cutoff
points were determined or what “normal” RR and HR were used. Subsequent studies (Akre et al., 2010;
Tucker, Brewer, Baker, Demeritt, &
Vossmeyer, 2009) using this tool used
the parameters listed in widely used
pediatric nursing textbooks (T.
Brewer, personal communication,
May, 2009).
In contrast, the Paediatric Early
Warning System Score (PEWS) and
the Bristol Paediatric Early Warning
Tool (PEW) have additional parameters, including oxygen therapy, demographics, medications, potassium levels, and seizure activities as indicators
of deterioration (Duncan et al., 2006;
Haines et al., 2006). These tools offer
age-specific parameters for VS; however, only Duncan et al. (2006) report
on the development of parameters,
which was by modified Delphi to garner expert opinion. No research studies were cited for VS parameters in the
early warning literature.
The objectives of the early warning research were directed at validating these tools rather than establishing parameters for specific VS. These
studies offer some guidance on VS as
indicators of deterioration. SBP was
included in several tools, but only
Parshuram et al. (2009) evaluated the
SBP score for ability to discriminate
between controls and ICU admissions. Although the SBP did not statistically predict ICU admission, the
authors evaluated it to be clinically
important and retained the SBP item
in the tool (Parshuram et al., 2009).
The Cardiff and Vale pediatric early
warning system and the PEWS tools
include a SBP item, but the reported
analyses include only the ability of
the tool as a whole to discriminate
and do not address the items separately (Duncan et al., 2006; Edwards et al.,
2009). The authors of the Brighton
tool noted that while adult early
warning tools use BP as a predictor,
change in BP is considered a late sign
of shock in children and was not included in the pediatric tool (Monaghan,
HR and RR are included in all
early warning tools reviewed. When
these parameters were evaluated for
ability to discriminate deterioration,
Haines and associates (2006) found
that bradycardia alone was not a predictor, and tachycardia was a useful
discriminator only when tachycardia
persisted following a fluid bolus of 2
to 20 ml/kg. However, tachypnea was
a useful discriminator (Haines et al.,
2006). Tume (2007) reviewed charts
from children with unplanned admission to ICU or high dependency units
(HDU) from the wards over a fourmonth period. This study using the
Bristol tool found that tachypnea
alone would have triggered the tool in
25% of those children admitted to
ICU. Tume (2007) noted that respiratory distress was the main reason for
admission in 55% cases of ICU admission and 54% HDU admissions.
A review of the early warning literature reveals there is lack of agreement on both the normative values
for VS and what is considered a critical change in those parameters. No
references to research studies were
found in determining VS criteria
within the early warning literature
The purpose of this review of the
evidence was to look to the current
literature to determine normative VS
values, as well as define abnormal or
significant changes in VS. To answer
the clinical question, “Among pediatric patient ages 1 through 5 years,
what are ‘normal’ VS parameters?”
the authors reviewed a sampling of
pediatric textbooks from the nursing
and medical disciplines. The current
normative HR and RR charts found in
medical and nursing textbooks are
inconsistent and are largely based on
expert opinion (Level VII) and not
based on research findings. Blood
pressure normative data most frequently cited the Fourth Report
(NHBPEP Working Group on High
Blood Pressure in Children and
Adolescents, 2004). This report was
primarily designed for identifying
hypertension in children and not to
define normative ranges, although
there has been some work on defining
hypotension. Normative values for
vital signs were inconsistent. How
those values were reported was also
inconsistent, with some values given
as ranges and others as means or
The inconsistency and paucity of
evidence cited in the development of
the VS charts prompted the authors
to search for studies designed to establish normative values in children 1 to
5 years of age. The research literature
has used descriptive design (Levels V
and VI) (Melnyk & Fineout-Overholt,
2011), which can be expected in
developing normative charts. Normative charts have been based on a normal distribution of values, but there is
inconsistency in the use of 5 and 95
percentiles (versus 2.5 and 90 or 97.5
percentiles) as the cutoff points for
normal values. Methods of collecting
VS data were inconsistent, despite literature on variations between different methods (Fleming et al., 2011;
Park & Menard, 1989; Rusconi et al.,
1994). One study measured RR by
means of observation of the fully
clothed child (Wallis et al., 2005), and
a second study listened with a stethoscope to the bare chest wall (Rusconi
et al., 1994). The inconsistency in the
methods of measuring may introduce
systematic error in synthesizing studies to determine normative values.
Epidemiological studies of VS parameters have also been criticized for
including children with unhealthy
characteristics, for example, including
hypertensive children in the sample
that may increase the upper limits of
normal BP (Rosner et al., 2008). A
2011 meta-analysis confirmed the
finding of inconsistency across the literature (Fleming et al., 2011). This
meta-analysis of the current evidence
resulted in parameters that differed
from those used in national and international life support guidelines on HR
and RR in young children, further
indicating more research is needed.
To answer the second clinical
question, “Among pediatric patient
ages 1 through 5 years, what is a significant clinical change in VS?” the
literature on Early Warning Systems
was reviewed. The normative VS values were inconsistent across the various systems. Additionally, not all
studies sought to identify which items
predicted deterioration of health status. When determining what change
in VS was predictive of deterioration,
tachypnea and respiratory distress
were the primary predictors (Haines
et al., 2006; Tume, 2007). Tachycardia
was a predictor only if fluid status had
been addressed (Haines et al., 2006).
Blood pressure as a sign of shock was
considered a late sign and was not
included in one pediatric tool for that
reason (Monaghan, 2005). Many
early warning tools rely on behavioral
changes and the nurses’ “worry” over
the child as indicators of impending
deterioration. Although there is good
evidence of the need for screening for
hypertension in children, support for
the use of BP as a predictor of deterioration is limited due lack of norma-
PEDIATRIC NURSING/September-October 2013/Vol. 39/No. 5
tive data on the low end of BP and the
lack of evidence in its usefulness as an
early indicator of health status.
Implications for Clinical
Practice and Future
The current normative VS parameters for children 1 to 5 years of age
are not supported by strong and consistent evidence. Therefore, these
authors recommend that in the acute
care setting, comparing and contrasting a child’s own VS measurement
changes throughout the shift or from
previous shifts will assist the clinician
in deciding the nursing intervention
needed (Zeitz & McCutcheon, 2006).
This nursing intervention is then
based on the changes within the
child’s parameters and on the current
clinical evidence. The frequency of VS
and interventions should be based on
the child’s condition or fluctuation in
their past values (Zeitz & McCutcheon,
2006). Additionally, an assessment of
VS should be coupled with behavioral
and physiological indicators, such as
decreased level of consciousness, capillary refill, and signs of respiratory
distress (Duncan, 2007; Royal College
of Nursing, 2011; Tucker et al., 2009;
Tume, 2007).
Although frequency of VS was
not examined in this study, given our
findings, the value of checking VS
every four hours is in question.
Reliance on VS parameters alone for
monitoring a child’s potential for
deterioration may delay predicting
decline and underplay the importance of other clinical indicators
(Evans et al., 2001). Doing routine VS
every four hours may place added
burden on the child and family in loss
of sleep. The cost in lost recuperative
sleep to patients and families along
with the costs of additional nursing
time must be weighed against the
benefit of routinely assessing VS,
which may not be the best indication
of deteriorating clinical status.
Future rigorous research aimed at
defining normal and abnormal VS is
needed. These studies should be based
on defined age groups, race, gender,
height, weight, activity level (awake/
asleep), BMI, and health status.
Methods of measurement are diverse
in the studies reviewed (for example,
the equipment used and position of
the child). Studies must be explicit in
the protocols used for gathering data,
and consistency across studies is
needed. Further studies that evaluate
the clinical and behavioral parameters that signal a child’s health
changes and deterioration are needed
to guide early interventions and allay
adverse outcomes. Other areas for
research include the assessment of
nursing time related to cost and
improved outcomes and patient risk
in terms of disrupted sleep.
Vital sign evaluation is often
based on routine tradition. Evidence
about normal values in young children is inconsistent and contradictory. Additionally, there is scarcity of
high-quality, consistent research on
normative VS values, the frequency of
assessments, and behavioral and physiologic indicators that detect a
decline in young hospitalized children. There are opportunities for further research in these areas. Clinicians
need VS guidelines based on research
to guide their clinical decision making and interventions.
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PEDIATRIC NURSING/September-October 2013/Vol. 39/No. 5
Instructions For
Continuing Nursing Education
Contact Hours
What Is ‘Normal?’
Evaluating Vital Signs
Deadline for Submission:
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PED 1308
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The purpose of this article is to review
the current literature and determine if
EBP exists for normalcy of vital signs in
the 1-5 year age groups.
1. Determine the best evidence for
normative parameters for VS in healthy
children 1 to 5 years of age.
2. List two determinates of vital sign
normalcy noted within the review of the
3. Discuss the implications for clinical practice and future research.
Statements of Disclosure: The authors
reported no actual or potential conflict of
interest in relation to this continuing nursing education activity.
The Pediatric Nursing Editorial Board
members reported no actual or potential
conflict of interest in relation to this continuing nursing education activity.
This independent study activity is provided
by Anthony J. Jannetti, Inc. (AJJ).
Anthony J. Jannetti, Inc. is accredited as a
provider of continuing nursing education by the
American Nurses Credentialing Center's Commission on Accreditation.
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approved by the California Board of Registered
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Licenses in the state of California must
retain this certificate for four years after the CNE
activity is completed.
This article was reviewed and formatted for
contact hour credit by Hazel Dennison, DNP,
RN, APNc, CPHQ, CNE, Anthony J. Jannetti
Education Director; and Judy A. Rollins, PhD,
RN, Pediatric Nursing Editor.