Date:  March 27, 2014

Guest Skeptic: Dr. Anthony Crocco Anthony is the pediatric member of the BEEM Dream Team. Anthony works at McMaster University and is the Medical Director and Division Head for Pediatric Emergency Medicine.

Case Scenario: 18 month old girl presents to the emergency department with viral gastroenteritis. She has vomiting, diarrhea and fever. Her heart rate is 165 beats per minute.

Screen Shot 2014-03-27 at 8.20.08 PMQuestion: What are the normal ranges for heart rate and respiratory rate in children?

Background: There are a number of ways you can assess pediatric vital signs.

  1. Clinical Gestalt
  2. PALS – Pediatric Advanced Life Support
  3. APLS – Advanced Pediatric Life Support
  4. Formula – a variety are available
  5. Apps – ex: PediStat

Article: Fleming S et al. Normal Ranges of Heart Rate and Respiratory Rate in Children from Birth to 18 Years of Age: A Systematic Review of Observational Studies. Lancet 2011; 377: 1011-18.

  • Population: Children 18 years and younger
Intervention: Observational studies on the normal heart rate or respiratory rate of children
  • Comparison: Reference ranges from existing text books
  • Outcome: No applicable

Authors Conclusions: “evidence-based centile charts for children from birth to 18 years”.

Quality Checklist:

  1. Clinically relevant question with an established criterion standard? Yes.
  2. Search detailed and exhaustive. No. The authors did a search of MEDLINE, EMBASE, CINHAL as well as checking reference lists. There were no language restrictions. The authors do not, however, discuss searching abstracts, conference proceedings or discussing with experts in the field.
  3. The methodological quality of primary studies were assessed for common forms of bias? Unsure. The authors did not address the quality of the studies included.
  4. Assessments of studies were reproducible? Unsure.
  5. Was there low between-study heterogeneity. Unsure.

Key Results: These figures present the summarized data from the 69 studies as well as how the pooled data relate to current norms presented by PALS and APLS.

Screen Shot 2014-03-27 at 8.08.34 PM


Screen Shot 2014-03-27 at 8.08.44 PM


Screen Shot 2014-03-27 at 8.08.51 PM

BEEM Comments: One of the more challenging aspects of pediatric emergency care is deciding when vital signs fall outside of the normal range. In the past, guidelines from PALS and APLS courses have directed care both at the nursing and physician level.

This well performed systematic review compiles all the data regarding normal heart rates and respiratory rates in children, including over 150,000 data points. The results provide a more accurate reflection of the normal ranges, with percentiles, for children of various ages.

The provided graphs should be used to replace current ‘best guess’ normal values. The implications for this research affect not only the physicians providing care, but also the nurses at triage deciding on level of acuity.

The Bottom Line: This is a well conducted systematic review of the pediatric normal values for heart rate and respiratory rate. The provided graphs should replace existing values from other sources.

Clinical Application: I quote and reference this paper ALL THE TIME!. Triage vitals at my hospital are measured against this graph. It is easy to have a PDF of these charts on your smart phone to use as a reference.

What do I tell my Patient: You daughters has abnormal vitals signs. I am going to treat her symptoms and see if we can make her better.

Case Resolution: 18 month old girl presents to the emergency department with viral gastroenteritis. She has vomiting, diarrhea and fever. Her heart rate is 165 beats per minute. I provide her with oral ondansetron (8-15kg=2mg, 15-30kg=4mg and >30kg=8mg) and oral rehydration therapy based upon our previous podcast SGEM#12: Oh Dance-a-Tron

Screen Shot 2014-03-27 at 8.35.21 PMKeener Kontest: Last weeks winner was Cornelia Härtel. She attended the SweetBEEM conference and saw the presentation on the Valsalva Maneuver. Clearly there must have been some knowledge translation. Cornelia knew that the Valsalva described the maneuver was to test the patency (openness) of the Eustachian tube. He also described the use of this maneuver to expel pus from the middle ear. I will be sending Cornelia the standard skeptical prize but also something special that relates back to Swedish culture.

If you want to play the Keener Kontest listen to the podcast for the question. Email me your answer at TheSGEM@gmail.com with “keener” in the subject line. The first person to correctly answer the question will receive a cool skeptical prize.

Remember to be skeptical of anything you learn,

even if you heard it on the Skeptics’ Guide to Emergency Medicine.