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http://www.pediatrics.org/cgi/content/full/99/6/e10
Martin U. Nwankwo, MD*; John M. Lorenz, MD*; and Joseph C. Gardiner, PhD‡
ABSTRACT. Objectives. Improvements in neonatal obtained by routine nurse measurements were signifi-
care have resulted in increasing survival of extremely cantly higher than those in either position using our
premature infants whose hospital course often runs into standard protocol (54.4 vs 47.0 or 49.1 mm Hg, P < .003).
weeks or months. Some interventions during the acute Moreover, the routine nurse measurements varied more
care of these neonates, such as umbilical catheterization widely than did those obtained using the standard pro-
and use of steroids, not infrequently result in elevation tocol. The standard deviation for the routine mean BP
of blood pressure (BP). It is, therefore, essential that these measurements by nurses was 11.4 compared with 6.8 and
infants be monitored accurately for possible hyperten- 8.2 for the first measurements in the prone and supine
sion during their convalescence. Unfortunately, norma- positions, respectively, with the standard protocol. The
tive data on BP in this population are scant and compar- mean BP measurements made in the supine position (the
ison of data from various studies is hampered by highest measurements obtained) using the standard pro-
methodologic differences in design. Studies in adults tocol were also significantly lower than published val-
address the necessity for a restful state, adopting a com- ues: 57 of 64 measurements were less than the average
fortable position, and attempts to reduce the startle re- mean BP for age described by Tan (J Pediatr. 1988; 112:
sponse to initial cuff inflation. Studies in the newborn 266 –270).
using the oscillometric technique have not addressed Conclusion. The statistically significant difference
these concerns. A standard BP measurement protocol was between the prone and supine position and among suc-
studied to determine the effect of ensuring a restful state, cessive measurements in each position are not clinically
startle response to cuff inflation, and infant position on relevant. The clinically significant differences between
BP in clinically stable low birth weight infants after the measurements obtained with this standard protocol and
first week of life. routine nursing measurements or published data are the
Study Design. The Dianamap oscillometer was used result of ensuring a restful state after cuff application.
to measure BP in infants with a birth weight <2500 g We believe that measurements thus obtained are more
between 7 and 42 days postnatal age. Each infant was representative of true resting BPs in these infants. We
studied only once when they were clinically stable. BP propose that a single measurement obtained after a rest-
was measured in two positions, prone and supine, in ful state has been assured after cuff application would be
random order. Infants were studied at least 11⁄2 hours practical for routine newborn care and be more represen-
after their last feeding or medical intervention. An ap- tative of basal BP than that obtained immediately after
propriate sized cuff was applied to the right upper arm cuff application. Normative data in convalescing low
and the infant was positioned according to randomiza- birth weight infants should be generated using a proto-
tion. The infant was then left undisturbed for at least 15 col that emphasizes a rest period after cuff application.
minutes or until the infant was sleeping or in a quiet Pediatrics 1997;99(6). URL: http://www.pediatrics.org/cgi/
awake state. Three successive BP recordings were taken content/full/99/6/e10; newborn, low birth weight, blood
at 2-minute intervals. The infant’s position was then pressure.
reversed and another 15 minutes of quiet time was al-
lowed. Thereafter, a second set of three successive BP
recordings were obtained. The most recent routine nurs- ABBREVIATION. BP, blood pressure.
ing BP measurement was also recorded. Data were ana-
lyzed using analysis of variance and are presented as
means and standard errors of the mean. Blood pressure (BP) monitoring is an important
Results. Sixty-four infants were studied. Birth part of neonatal intensive care both for the acutely ill
weights ranged from 901 to 2423 g and gestational ages and the convalescing neonate. The most accurate
from 26 to 37 weeks. Overall, mean BP was significantly method of measuring BP is by direct intraarterial
lower in the prone than supine positions (45.7 6 0.7 vs recordings.1 However, this method is associated with
47.8 6 0.8 mm Hg, P < .002). In either position, the first serious complications related to arterial catheteriza-
measurement was significantly higher than the third (av- tion2,3 and the procedure itself may be technically
erage difference was 3 mm Hg, P < .003). In general, the
relationships among position and order of measurement
difficult, especially in low birth weight infants.
were similar for systolic and diastolic BP. Mean BPs Therefore, direct intraarterial recordings are usually
reserved for those infants whose conditions are suf-
ficiently serious to justify arterial catheterization.
From the *Regional Children’s Center, Sparrow Hospital, Lansing, Michi-
gan and the Department of Pediatrics and Human Development; and the
Of the noninvasive methods of BP recordings, the
‡Program in Epidemiology, College of Human Medicine, Michigan State oscillometric technique is the most widely accepted
University, East Lansing, Michigan. method in current use. The oscillometric technique is
Received for publication Oct 11, 1996; accepted Feb 21, 1997. based on the fact that pulsatile blood flow sets off
Reprint requests to (M.U.N.) Detroit Riverview Hospital, NICU, 7733 E.
Jefferson Ave, Detroit, Michigan 48214.
oscillations in the arterial wall that are transmitted to
PEDIATRICS (ISSN 0031 4005). Copyright © 1997 by the American Acad- a cuff placed around the limb.4 When used correctly,
emy of Pediatrics. BPs obtained by this method correlate well with
We then compared routine nurse readings with than did those reported by Tan. Moreover, the
the first readings in prone and supine positions, the variance of measurements obtained using our stan-
highest measurements using our standard protocol. dard protocol was significantly less than in routine
Mean BPs obtained by routine nurse measurements measurements and less than those of Tan.12
were significantly higher than those in either posi- Our data also confirms earlier reports by Park
tion using our standard protocol. Moreover, the rou- and Menard13 that BPs tend to decrease with re-
tine nurse measurements varied more widely than peated measurements. The first BP measurements
did those obtained using our standard protocol. The were significantly higher than the second or third,
standard deviation for the routine mean BP measure- but these differences were of small magnitude.
ments by nurses was 11.4 compared with 6.8 and 8.2 Findings such as this have led some to the sugges-
for the first measurements in the prone and supine tion that the average of two or three readings be
positions, respectively, with our standard protocol. used for BP measurements in children. However,
We then compared our results with those pub- we believe that these differences, although statis-
lished by Tan,12 who used the Dianamap oscillometer tically significant, are not of clinical relevance. We
to study BPs in low birth weight infants in the first 10 propose that a single measurement obtained after a
weeks of life. Tan studied infants with birth weights restful state has been assured after cuff application
,1500 g, whereas we included babies with birth would be practical for routine newborn care and be
weights of ,2500 g (range, 901 to 2423 g). The mean more representative of basal BP than that obtained
birth weight in our study was 1652 6 386 g, com- immediately after cuff application. It must also be
pared with 1221 6 171 g in Tan’s study. Figure 1 emphasized that selecting an appropriate-sized
shows a scattergram of the first mean BP readings in cuff remains a key requirement for any indirect
the supine position by our standard protocol (the method for BP measurement.
highest measurement we obtained) compared with In conclusion, we suggest that normative data in
data of Tan.12 convalescing low birth weight infants should be gen-
erated using a protocol like this one, which empha-
DISCUSSION sizes a rest period after cuff application. We have
Our data indicate that BP measurements using demonstrated that this protocol results in lower BPs
our protocol were significantly lower than those with less variance. We believe that measurements
recorded as part of routine nursing care and lower thus obtained are more representative of true resting
than those previously reported by Tan.12 We be- BPs in these infants.
lieve that these clinically significant differences are
the result of assuring a restful state in the subjects REFERENCES
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