Pediatrics International (2012) 54, 182189

doi: 10.1111/j.1442-200X.2011.03520.x

Original Article

ped_3520

182..189

Delivery room blood pressure percentiles of healthy, singleton, liveborn neonates

zgl Salihog lu,1 Emrah Can,1 Ays egl Bes kardes ,1 Begm S irin Ko,1 Ilhan Tan,1 Gnay Can3 and Sami Hatipog lu2 1 Neonatal Intensive Care Unit, 2Department of Pediatrics, Bakrky Dr. Sadi Konuk Training and Research Hospital, and 3 Department of Public Health, Cerrahpasa Medical Faculty, Istanbul, Turkey
Abstract Background: Arterial blood pressure (BP) is one of the four vital signs that reect cardiovascular status in neonates. The present study aimed to obtain BP percentiles among healthy, singleton, liveborn neonates between 34 and 43 weeks of gestation who were less than 1 h old. Methods: BP measurements were taken after birth in supine-positioned neonates in the delivery room using an oscillometric device. A total of 982 well-nourished neonates who did not require resuscitation, were not fetally malnourished, were not admitted to the neonatal intensive care unit and were without obvious congenital abnormalities were included in the study. Results: Sex- and type-of-delivery-specic 5th and 95th percentiles BP measurements were obtained for gestation. Mean BP values for systolic, diastolic and mean of term neonates were 63.98 1 12.29 mmHg, 38.34 1 11.06 mmHg and 49.32 1 11.33 mmHg, and late preterm neonates were 61.80 1 12.46 mmHg, 33.17 1 9.97 mmHg and 46.52 1 10.8 mmHg, respectively. There were weak but signicant correlations between birthweight, birth length and head circumference and systolic, diastolic and mean arterial BP values (r = 0.20, r = 0.15 and r = 0.20, respectively, P < 0.001). Neonates who were delivered vaginally had higher mean BP values for systolic, diastolic and mean than neonates delivered by cesarean section (P < 0.05). Female neonates had higher systolic BP values than male neonates (P < 0.05). Conclusion: Data presented in this study include sex- and delivery-mode-specic BP percentile curves using an oscillometric method and serve as a valuable reference for physicians in dealing with the management of singleton, liveborn late preterm and term newborns in the delivery room intensive care.

Key words blood pressure, neonate, oscillometric device.

Arterial blood pressure (BP) is one of the four vital signs that best reect cardiovascular status during the newborn physical examination and is essential in the management of the high-risk neonate.1,2 Newborn BP is seldom measured in the delivery room.3 Most established normative BP data from neonates were collected from ill newborns in the neonatal units more than 1224 h after delivery.4,5 The rst study of this type was from London in 1956 and reported neonatal systolic BP at birth.6 Non-invasive BP measurement using an oscillometric method as an indirect BP measurement technique is one of the four non-invasive methods used to measure BP in newborn infants.1,7,8 Oscillometry is easy to use, and it measures arterial BP and eliminates observer variability.1 As opposed to the oscillometric method, other non-invasive techniques (sphygmomanometric, ultrasonic technique and palpatory method) are not practical, are

inaccurate for newborns and are unable to provide mean and diastolic arterial BP.1,9 The purpose of the present study was to obtain BP (systolic, diastolic and mean) percentiles in healthy, singleton neonates who were less than 1 h old and born between 34 and 43 weeks of gestation (WG). Neonates were delivered at Bakrky Dr. Sadi Konuk Training and Research Hospital, Istanbul, Turkey, and BP was assessed using an oscillometric device.

Methods
In this prospective study, a total of 982 healthy, singleton, liveborn neonates between 34 and 43 WG who were born at our hospital from January 2008 to June 2009 were included. Approximately 10 neonates per day are born in our multidisciplinary hospital, which has both adult and neonatal intensive care units. Exclusion criteria included neonates with obvious congenital abnormalities, term (3742 completed WG) and post-term (>42 completed WG) neonates with fetal malnutrition according to the Clinical Assessment of Nutritional Status (CANS) score,10,11 neonates who required active resuscitation with/without tracheal meconium aspiration and neonates who were admitted to the

Correspondence: zgl Salihog lu, MD, Kalams Fener Caddesi Kalams Apartman, B Blok No: 54, 34726 Kadky, Istanbul, Turkey. Email: fbozgulsalih@yahoo.com Received 8 May 2011; revised 4 November 2011; accepted 15 November 2011.

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Delivery room blood pressure of neonates

neonatal intensive care unit. Maternal pregestational and gestational disorders were not taken into consideration. BP (systolic, diastolic and mean) was measured immediately after birth between the 1.5th and 5th minutes of postnatal transitional period of life in stable and supine-positioned neonates under the radiant warmer in the delivery room. Measurements were acquired after clamping of the umbilical cord at delivery and before the intramuscular administration of prophylactic vitamin K and anthropometric measurements (birthweight [BW], birth length [L] and head circumference [HC]). An automated indirect oscillometric technique was employed on the babys series right brachium using a vital signs monitor (LifeScope I oscillometric device, Nihon Kohden, Tokyo, Japan). An appropriate cuff size, where the bladder width covered at least 40% of the circumference of the arm and the length covered 80% of the length of the arm (length between the olecranon and acromion), was used.1 The BP measurements were taken and noted by the authors. When one of the systolic, diastolic or mean blood pressure values was not obtained at the rst measurement, the second or third measurement was performed to determine the BP value. All investigators used the same protocol. Gestational age was determined by the rst day of the mothers last menstrual period or by obstetric ultrasonography conrmed by the New Ballard Score.12 Newborns were classied as small for gestational age (SGA), appropriate for gestational age (AGA) or large for gestational age (LGA) on the basis of normograms of the Lubchencos intrauterine growth curves,13 and their birthweights were categorized as <2.5 kg, between 2.5 and 4 kg and >4 kg. Ethical approval for the study was obtained from the hospitals ethics committee. Results were analyzed with spss for Windows, version 10.0 (spss, Chicago, IL, USA). ancova, adjusted for the number of completed gestational weeks, was used to compare groups. Pearsons method was used for the correlation analysis. P-values < 0.05 were considered statistically signicant.
Table 1 Describe the study population (n = 982) characteristics n Sex Male Female Mode of delivery Vaginal Cesarean section Birthweight categories <2500 g 25004000 g >4000 g Newborn classication AGA SGA LGA 513 469 424 558 45 873 64 838 20 124

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% 52.2 47.8 43.2 56.8 4.6 88.9 6.5 85.3 2.0 12.6

AGA, appropriate for gestational age; LGA, large for gestational age; SGA, small for gestational age.

Results
The characteristics of the study population are summarized in Table 1. BP measurements of 982 singleton, liveborn neonates (469 female [47.8%] and 513 male [52.2%]) born after 3443 completed WG were obtained. Of these neonates, 424 (43.2%) neonates were delivered vaginally, and 558 (56.8%) neonates were delivered by cesarean section. Additionally, 873 (88.9%) neonates weighed 25004000 g, and 838 (85.3%) were AGA. Neonatal anthropometric measurement, including mean arterial BP values in mmHg, are presented in Table 2. Mean BW was 3279.90 1 478.81 g, mean birth L was 48.51 1 2.20 cm, mean HC was 34.43 1 1.46 cm and mean WG was 39.01 1 1.49 weeks. Mean BP values were 63.82 1 12.24 mmHg for systolic BP (SBP), 37.76 1 11.63 mmHg for diastolic BP (DBP) and 49.01 1 11.40 mmHg for mean BP (MBP). Mean BW, mean birth L, mean HC, and WG were 3348.52 1 429.83 g, 48.80 1 2.0 cm, 34.52 1 1.83 cm and 39.28 1 1.05 weeks in term neonates, respectively. Mean BW, mean birth L, mean HC, and mean WG were 2655.18 1 392.16g, 45.82 1 2.03 cm, 33.12 1 1.43 cm, and 35.98 1 1.09 weeks in late preterm

neonates, respectively. Mean BP values for systolic BP (SBP), diastolic BP (DBP), and mean BP (MBP) of term neonates were 63.98 1 12.29 mmHg, 38.34 1 11.06 mmHg, and 49.32 1 11.33 mmHg. Mean BP values for systolic BP (SBP), diastolic BP (DBP), and mean BP (MBP) of late preterm neonates were 61.80 1 12.46 mmHg, 33.17 1 9.97 mmHg and 46.52 1 10.8 mmHg, respectively. Correlations between anthropometric measurements and BP measurements are presented in Table 3. There were weak but signicant correlations between BW and systolic, diastolic and mean arterial BP values (r = 0.20, r = 0.15 and r = 0.20, respectively, P < 0.001). The correlations between BL and systolic, diastolic and mean arterial BP measurements were also weak but signicant (r = 0.15, r = 0.14 and r = 0.13, respectively, P < 0.001). There were also weak but signicant correlations between HC and both systolic and mean arterial BP measurements (r = 0.10 and r = 0.12, respectively, P < 0.001). Mean SBP, DBP and MBP values were analyzed with respect to sex, mode of delivery, newborn classication and category of birthweight (Table 4). The mean SBP of neonates less than 1 h old was signicantly higher in girls than in boys (P < 0.05). Mean SBP, DBP and MBP values of neonates less than 1 h old born vaginally were signicantly higher than those neonates born by cesarean section (P = 0.000, P = 0.000 and P = 0.005, respec-

Table 2 Neonatal delivery room data, including mean arterial blood pressure values n 982 982 982 982 982 982 982 Mean 1 SD 3279.90 1 478.81 48.51 1 2.20 34.43 1 1.46 39.01 1 1.49 63.82 1 12.24 37.76 1 11.63 49.01 1 11.40 Range 16205260 4056 3040 3443 26106 1581 1790

Birthweight (g) Birth length (cm) Head circumference (cm) Weeks of gestation SBP (mmHg) DBP (mmHg) MBP (mmHg)

DBP, diastolic blood pressure; MBP, mean blood pressure; SBP, systolic blood pressure.

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Table 3 Correlation of blood pressure values with anthropometric measurements taken in the delivery room Birthweight (g) SBP (mmHg) DBP(mmHg) MBP (mmHg) r 0.2000 0.1529 0.1964 P 0.000*** 0.000*** 0.000*** Birth length (cm) r 0.1509 0.1305 0.1399 P 0.000*** 0.000*** 0.000*** Head circumference (cm) r 0.1027 0.0352 0.1171 P 0.001*** 0.255 0.000***

***P < 0.001. DBP, diastolic blood pressure; MBP, mean blood pressure; SBP, systolic blood pressure.

tively). The means of the SBP, DBP and MBP of LGA neonates were signicantly higher compared to both AGA and SGA neonates (P = 0.001, P = 0.01 and P = 0.04, respectively). There were statistically signicant differences between the mean SBP, DBP and MBP values of neonates weighing greater than 4000 g, between 2500 and 4000 g and less than 2500 g (P = 0.000, P = 0.000 and P = 0.023, respectively). Mean arterial BP values of healthy neonates are presented in Table 5 according to WG. At 40 WG, the mean SBP was 64.89 1

12.35 mmHg, the mean DBP was 39.24 1 12.25 mmHg and the mean MBP was 50.05 1 11.67 mmHg. SBP, DBP and MBP percentiles of healthy, singleton, liveborn neonates aged 3443 WG are presented in Table 6. BP percentile values varied according to WG. According to these percentiles values, the 10th percentiles of SBP, DBP and MBP at 40 WG were 49.10 mmHg, 25.00 mmHg and 36.00 mmHg, respectively. The 50th percentiles of SBP, DBP and MBP were 65.00 mmHg, 38.00 mmHg and 49.00 mmHg, respectively. The

Table 4 Comparison of arterial blood pressure values in the study population according to sex, mode of delivery, newborn classication and birthweight categories SBP (mmHg) Sex Male (n = 513) Female (n = 469 ) P Mode of delivery Vaginal (n = 424) Cesarean section (n = 558) P Newborn classication LGA (n = 124) AGA (n = 838) SGA(n = 20) P Birthweight categories <2500 g (n = 46) 25004000 g (n = 873) >4000 g (n = 64) P 62.96 1 0.54 64.76 1 0.56 0.022 65.77 1 0.59 62.34 1 0.51 0.000*** 67.23 1 1.10 63.51 1 0.42 55.73 1 2.72 0.000*** 57.61 1 1.97 63.80 1 0.41 68.53 1 1.55 0.000*** DBP (mmHg) 37.44 1 0.51 38.10 1 0.53 0.375 39.73 1 0.55 36.25 1 0.48 0.000*** 40.45 1 1.04 37.46 1 0.40 33.25 1 2.58 0.007** 33.71 1 1.87 37.76 1 0.39 40.49 1 1.47 0.025* MBP (mmHg) 48.41 1 0.50 49.65 1 0.52 0.086 50.16 1 0.55 48.12 1 0.48 0.006** 52.33 1 1.02 48.64 1 0.39 43.90 1 2.54 0.001*** 43.08 1 1.84 48.96 1 0.38 53.80 1 1.44 0.000***

*P < 0.05, **P < 0.01, ***P < 0.001. AGA, appropriate for gestational age; DBP, diastolic blood pressure; LGA, large for gestational age; MBP, mean blood pressure; SBP, systolic blood pressure; SD, standard deviation; SGA, small for gestational age. Table 5 Mean arterial blood pressure values of healthy neonates according to weeks of gestation WG n = 982 513 boys/ 469 girls 13(7/6) 16 (8/8) 27 (16/11) 47 (25/22) 212 (98/114) 309 (162/147) 240 (126/114) 84 (48/36) 23 (14/9) 11 (9/2) % 1.3 1.6 2.7 4.8 21.6 31.5 24.4 8.6 2.3 1.1 SBP (mmHg) Mean 1 SD 57.69 1 15.13 63.13 1 12.00 58.11 1 9.08 62.17 1 13.65 62.50 1 12.73 64.77 1 12.12 64.89 1 12.35 64.48 1 10.65 64.30 1 10.04 63.00 1 11.90 DBP (mmHg) Mean 1 SD 30.92 1 9.57 32.50 1 12.63 31.15 1 7.13 33.89 1 10.13 37.17 1 11.01 38.18 1 11.58 39.24 1 12.25 38.74 1 12.06 40.57 1 9.82 40.18 1 15.39 MBP (mmHg) Mean 1 SD 41.85 1 10.38 47.94 1 14.96 42.70 1 6.08 47.13 1 11.29 48.75 1 11.43 49.16 1 11.38 50.05 1 11.67 50.27 1 11.13 48.91 1 8.64 50.82 1 12.70

34 35 36 37 38 39 40 41 42 43

DBP, diastolic blood pressure; MBP, mean blood pressure; SBP, systolic blood pressure; SD, standard deviation; WG, weeks of gestation.

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95th 59.00 84.00 55.20 72.80 68.35 69.50 71.90 69.75 67.00 79.00

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Table 6 Systolic, diastolic and mean blood pressure (mmHg) percentiles of healthy, singleton, liveborn neonates at 3443 weeks of gestation

5th 30.00 24.00 33.20 28.80 31.65 31.00 34.00 33.00 32.80 32.00

90th percentiles of SBP, DBP and MBP were 81.00 mmHg, 56.90 mmHg and 66.00 mmHg, respectively. The lowest SBP value seen at the 50th percentile was >55 mmHg, and all of the values at the 50th percentile were between 56.00 mmHg and 65.50 mmHg among neonates born between 34 and 43 WG. The lowest DBP value seen at the 50th percentile was >28 mmHg, and all of the values at the 50th percentile were between 29.00 mmHg and 41.00 mmHg in neonates between 34 and 43 WG. The 5th, 10th, 25th, 50th, 75th, 90th and 95th percentile curves for SBP, DBP and MBP measured within an hour of birth are shown in Figure 1. The 5th to 95th percentiles of SBP, DBP and MBP for male and female neonates born at 3443 WG are presented in Table 7. Arterial BP percentiles of the healthy, singleton, liveborn neonates delivered vaginally and by cesarean section are presented in Table 8.

MBP percentiles (mmHg)

10th 30.00 30.30 35.00 30.80 35.00 35.00 36.00 35.50 37.60 33.80

25th 32.00 41.00 37.00 41.00 41.00 41.50 42.00 43.00 43.00 43.00

50th 44.00 43.50 42.00 46.00 47.00 49.00 49.00 50.50 47.00 48.00

75th 51.50 58.00 48.00 53.00 56.00 56.00 57.00 56.75 54.00 60.00

90th 57.40 71.40 50.80 62.80 65.70 65.00 66.00 64.50 62.20 75.20

Discussion
During the past 30 years, few studies have documented changes in BP with gestational age during the rst hours of life in term and preterm infants and no other studies in the literature have been conducted in healthy, singleton, liveborn, late preterm, term and post-term neonates in the transition period of postnatal life.5,1416 Our study is the rst study to ascertain sex- and delivery-mode-specic BP percentiles during the transitional period of life in the delivery room. The rst published neonatal BP study at birth was performed by Holland and Young6 in 1956 by palpating the brachial artery below an inatable cuff. They compared the average SBP at birth of neonates in various conditions, such as abnormal deliveries, abnormal pregnancies (e.g., pre-eclampsia), premature infants and among twins. Their BP measurement method differed from our study; however, the time of measurement is similar to our protocol. They did not ascertain any diastolic or mean arterial BP values. De Swiet et al.17,18 presented the rst BP data in term neonates on day 4 of life. However, these studies provided only SBP values. Zubrow et al.19 reported BP reference ranges for neonates born at more than 36 WG with a variety of problems admitted to a neonatal intensive care unit (NICU). In contrast, our study population included only healthy, singleton, 3443 WG neonates without any conditions or therapy; we did not collect data from neonates admitted to the NICU. Zubrows study reported systolic and diastolic BP ranges, but no mean BP measurements were provided, whereas our study provided systolic, diastolic and mean BP percentiles of healthy, singleton, late preterm, term and post-term neonates.19 A correlation between BP and BW was previously reported.1,20 Pejovic et al.21 reported that BW was the most predictive factor of BP in a study of non-critically ill preterm and full-term neonates. However, Kent et al.5 reported no signicant differences in BP depending on BW or L among term infants. Similarly, Hegyi et al.22 reported that BW was not associated with any of the BP variables in premature neonates admitted to the NICU. The observed increases in BP in our study were positively correlated with BW, L and HC. We did not nd any previous reports of signicant correlations between HC and BP.
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90th 45.40 57.90 41.00 47.20 51.00 54.00 56.90 57.50 54.20 71.00 DBP percentiles (mmHg) SBP percentiles (mmHg) WG 34 35 36 37 38 39 40 41 42 43 5th 37.00 38.00 45.20 38.40 44.65 43.00 45.10 43.75 38.00 50.00 10th 39.40 47.80 48.60 40.00 48.00 49.00 49.10 49.50 47.60 50.40 25th 45.00 55.50 50.00 54.00 54.00 58.00 57.00 58.00 60.00 53.00 50th 58.00 61.00 56.00 62.00 61.00 65.00 65.00 65.50 65.00 62.00 75th 69.00 71.00 63.00 72.00 69.75 72.00 72.00 72.00 71.00 73.00 90th 84.40 78.70 73.60 80.20 77.00 79.00 81.00 78.00 75.60 84.40 95th 90.00 92.00 77.20 88.80 85.35 84.50 88.00 80.00 80.80 87.00 5th 18.00 17.00 20.00 20.40 22.00 22.00 21.00 23.00 23.60 22.00 10th 19.20 18.40 21.60 21.80 25.00 25.00 25.00 25.00 26.80 22.60 25th 22.00 23.00 26.00 26.00 29.00 30.00 30.00 29.25 33.00 28.00 50th 29.00 29.00 31.00 32.00 36.00 36.00 38.00 36.50 39.00 41.00 75th 39.50 38.00 36.00 40.00 43.75 44.00 46.00 44.00 48.00 44.00

95th 49.00 60.00 46.80 50.60 60.35 62.00 62.95 64.25 57.40 74.00 DBP, diastolic blood pressure; MBP, mean blood pressure; SBP, systolic blood pressure; WG, weeks of gestation.

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Fig. 1 The systolic, diastolic and mean blood pressure curves from healthy, singleton, liveborn neonates born at 3443 weeks of gestation are shown. , 5th; , 10th; , 25th; , 50th; , 75th; , 90th; , 95th. 2011 The Authors Pediatrics International 2011 Japan Pediatric Society

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Table 7 Systolic, diastolic and mean arterial blood pressure percentiles of healthy, singleton, liveborn, male and female neonates born at 3443 weeks of gestation WG 34 35 36 37 38 39 40 41 42 43 34 35 36 37 38 39 40 41 42 43 34 35 36 37 38 39 40 41 42 43 5th 43.00 55.00 47.00 39.30 45.95 39.00 45.70 40.45 37.00 50.00 21.00 17.00 20.00 19.60 21.95 21.00 25.00 22.45 26.00 28.00 30.00 24.00 32.00 24.40 30.00 28.00 34.35 31.45 32.00 32.00 10th 43.00 55.00 48.40 40.00 47.90 46.00 49.70 46.60 46.50 50.00 21.00 17.00 20.00 21.00 24.00 22.00 28.00 23.00 27.00 28.00 30.00 24.00 34.10 31.80 35.90 32.30 36.00 34.90 34.00 32.00 25th 50th 75th 90th 95th 76.00 71.00 69.00 96.20 84.15 79.85 89.00 79.10 82.00 87.00 40.00 60.00 48.00 65.00 51.55 62.00 64.00 69.40 58.00 74.00 59.00 66.00 50.00 74.70 68.00 70.85 69.65 70.85 68.00 79.00 5th 37.00 38.00 44.00 35.45 42.00 46.40 45.00 50.25 42.00 52.00 18.00 22.00 26.00 20.30 21.75 25.00 20.00 24.85 23.00 22.00 30.00 33.00 36.00 28.30 31.75 35.00 32.00 33.00 40.00 41.00 10th 37.00 38.00 45.20 41.00 49.50 50.80 49.00 53.70 42.00 52.00 18.00 22.00 26.40 22.60 25.00 26.80 22.50 25.70 23.00 22.00 30.00 33.00 36.00 30.30 34.00 37.80 36.00 36.70 40.00 41.00 25th 50th 75th 90th 90.00 92.00 77.60 78.20 81.50 80.40 81.50 80.00 75.00 53.00 95th 90.00 92.00 78.00 80.85 87.25 88.20 86.25 85.05 75.00 53.00 49.00 57.00 45.00 45.85 61.25 61.20 62.25 62.90 55.00 25.00 55.00 84.00 56.00 59.40 70.75 69.00 74.25 72.10 61.00 43.00

SBP percentiles (mmHg) in boys 47.00 51.00 65.00 76.00 57.50 60.50 68.50 71.00 50.00 56.00 61.00 69.00 54.00 60.00 72.00 87.20 53.00 60.00 68.00 76.10 57.00 64.00 71.00 78.00 58.00 66.00 72.00 81.00 55.50 64.00 69.75 73.30 59.75 65.50 72.50 79.00 54.00 63.00 73.50 87.00 DBP percentiles (mmHg) in boys 22.00 26.00 39.00 40.00 20.00 30.50 38.00 60.00 22.50 27.50 35.00 42.40 27.50 32.00 41.00 50.40 28.75 35.00 42.00 48.00 29.00 35.50 43.00 53.70 31.00 38.50 48.00 58.00 28.25 35.00 43.00 54.20 32.50 40.00 53.00 55.50 32.00 42.00 51.50 74.00 MBP percentiles (mmHg) in boys 32.00 35.00 47.00 59.00 41.25 42.50 47.00 66.00 37.00 42.00 45.00 49.30 39.50 45.00 55.50 72.20 39.75 46.00 54.25 66.00 39.00 47.00 56.00 65.00 44.00 50.00 58.25 67.00 42.00 50.00 56.00 62.30 42.25 48.50 57.00 65.50 45.00 48.00 60.00 79.00

SBP percentiles (mmHg) in girls 41.50 58.00 77.25 52.75 66.00 73.00 51.00 56.00 73.00 55.50 62.50 70.75 54.75 62.50 72.00 59.00 65.00 73.00 56.00 64.00 71.25 61.00 67.00 75.75 60.50 64.00 68.00 52.00 52.50 53.00

DBP percentiles (mmHg) in girls 21.00 34.00 42.25 49.00 24.25 29.00 42.50 57.00 30.00 33.00 36.00 43.60 24.00 31.50 39.25 43.80 28.75 37.50 47.25 55.50 30.00 38.00 45.00 54.00 29.75 36.50 44.25 51.50 32.50 39.00 45.00 59.90 34.00 38.00 47.50 55.00 22.00 23.50 25.00 25.00 MBP percentiles (mmHg) in girls 31.50 47.00 53.50 55.00 35.00 51.50 63.25 84.00 39.00 44.00 49.00 55.60 43.50 46.00 52.25 55.40 42.75 49.50 57.00 65.00 44.00 50.00 57.00 64.20 40.00 48.50 56.00 62.50 43.25 51.00 58.75 66.90 44.50 46.00 50.50 61.00 41.00 42.00 43.00 43.00

DBP, diastolic blood pressure; MBP, mean blood pressure; SBP, systolic blood pressure; WG, weeks of gestation.

In our study, the mean SBP of female neonates was signicantly higher than those of male neonates during the transitional period of life. Emery et al.23 reported that the female SBP values were higher than the male neonates on the rst day of life. Biologic variability of beta-adrenergic receptor activity and cortisol surge in the perinatal period may explain this difference. However, in the study reported by Hegyi et al.,22 during the rst 36 h of life, the range of BP in male and female healthy, premature neonates weighing less than or equal to 2000 g was similar. The mean BP values of all neonates delivered vaginally were statistically higher than the mean BP value of all neonates delivered via cesarean section, conrming data from the Holland and Young6 study. A relatively early clumping and less gravity effect after cesarean section delivery, anesthesia administered to the mother, and the cesarean section performed before the onset of labor may explain this difference. Holland and Young6 observed that neonates delivered by cesarean section tended to have lower BP than neonates delivered vaginally. However, in a study reported by Earley et al.,15 complicated deliveries, including cesarean sections, were not associated with a BP that differed

signicantly from normal deliveries. Furthermore, our study provides BP percentiles of neonates delivered vaginally and by cesarean section. The signicantly higher BP among LGA neonates compared with SGA and AGA neonates during the transition period may reect the increase in BP with increasing BW because the BP of neonates weighing >4000 g were signicantly higher than the BP of neonates weighing 25004000 g and <2500 g. Similar ndings were reported by Sadoh et al.24 in African, full-term neonates between the ages of 1 and 4 days. In this study, we observed that BP percentile values varied according to WG with the lowest values being reported at 34 WG. Gestational maturation of the autonomic nervous system activity and the sympathetic vasomotor action modulated by central respiratory activity may explain the mechanism of the BP difference according to the gestational ages. Pejovic et al.21 studied BP in non-critically ill preterm and full-term neonates admitted to the NICU. On day 1 of life, the mean SBP, DBP and MBP values of neonates at 3336 WG were lower than those of neonates 337 WG, and reported that gestational age was one of the predictive factors for BP. In a study by Adams et al.,25 MBP measured
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between 3 and 15 h of age correlated signicantly with gestational age. Moreover, Spinazzola et al.26 observed a trend of increasing BP with increasing gestational age for the rst week after birth. Both studies are consistent with our results. However, Hegyi et al.,22 reported that among healthy, premature infants weighing 5012000 g, the limits of SBP and DBP were independent of gestational age. Immaturation of the autonomic nervous system activity and the sympathetic vasomotor action may act in this situation. In conclusion, we reported correlations between BP and BW, BL and HC. BP values increased with increasing gestational age. The data presented in this study provide sex- and delivery-modespecic BP percentile curves and may serve as a valuable reference for physicians dealing with the management of singleton, liveborn neonates born at 3443 WG in the delivery room intensive care. The oscillometric method used in the current study is convenient and easy to use in neonates at birth in the delivery room, where invasive intra-arterial BP measurements are not practical.
MBP (mmHg) percentiles in vaginal delivery 32.00 32.00 32.00 47.00 55.00 55.00 55.00 42.00 42.00 43.50 53.00 64.00 66.00 66.00 40.00 40.00 41.50 45.00 50.75 56.00 56.00 39.00 39.40 44.00 47.00 55.50 61.20 62.00 31.40 35.60 42.00 51.00 59.00 66.20 68.60 32.45 35.90 43.00 49.00 58.75 66.00 70.55 34.00 36.00 41.00 51.00 57.00 66.80 73.90 33.50 36.00 42.50 51.00 56.50 65.00 69.50 32.00 32.00 45.00 50.00 58.50 68.00 68.00 44.00 44.00 45.00 53.00 59.50 60.00 60.00 MBP (mmHg) percentiles in cesarean section 30.00 30.00 31.50 39.50 50.75 58.40 59.00 24.00 26.70 35.00 42.50 54.75 78.30 84.00 32.30 35.00 36.50 42.00 46.00 49.80 53.60 26.50 30.00 39.50 45.00 53.00 68.50 74.25 31.30 34.60 40.50 46.00 53.00 64.20 69.40 30.00 35.00 40.00 48.00 55.00 63.00 69.00 34.00 36.00 43.00 49.00 56.00 66.00 70.00 31.80 34.20 43.00 50.00 57.00 63.60 76.00 36.00 38.00 42.25 46.50 52.25 60.50 61.00 32.00 32.00 41.00 46.00 60.00 79.00 79.00 DBP (mmHg) percentiles in vaginal delivery 26.00 26.00 26.00 39.00 39.00 39.00 39.00 29.00 29.00 30.50 35.00 53.75 60.00 60.00 31.00 31.00 31.75 34.00 39.75 45.00 45.00 28.00 29.20 31.00 35.00 43.50 48.40 50.00 22.80 25.00 33.00 40.00 48.00 54.20 60.60 22.45 26.00 32.00 38.50 48.00 55.10 65.30 22.20 28.00 31.00 39.00 48.00 56.00 62.70 23.00 25.00 30.00 37.00 45.00 59.00 66.50 26.00 26.00 29.50 37.00 50.00 58.00 58.00 33.00 33.00 35.00 41.50 42.75 43.00 43.00 DBP (mmHg) percentiles in cesarean section 18.00 18.30 21.75 27.50 40.00 48.10 49.00 17.00 17.60 22.25 27.00 37.25 53.70 57.00 20.00 20.40 24.50 28.00 35.50 39.60 47.20 19.75 21.00 24.00 30.50 39.00 47.50 56.00 21.30 24.00 28.00 34.00 40.00 49.40 60.80 21.00 24.00 29.00 34.00 42.00 48.80 61.80 20.00 25.00 30.00 36.00 44.00 58.00 64.00 22.80 24.60 29.00 35.00 43.00 57.20 64.20 23.00 28.00 34.50 40.00 49.25 54.00 55.00 22.00 22.00 25.00 31.00 59.00 74.00 74.00

Table 8 Arterial blood pressure percentiles of the healthy, singleton, liveborn neonates delivered vaginally and by cesarean section

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25th

50th

75th

90th

95th

References
DBP, diastolic blood pressure; MBP, mean blood pressure; SBP, systolic blood pressure; WG, weeks of gestation. 1 Nuntnarumit P, Yang W, Bada-Ellzey HS. Blood pressure measurements in the newborn. Clin. Perinatol. 1999; 26: 98196. 2 Kourembanas S. Shock. In: Cloherty JP, Eichenwald EC, Stark AR (eds). Manual of Neonatal Care, 5th edn. Lippincott Williams and Wilkins, Philadelphia, PA, 2008; 17680. 3 American Academy of Pediatrics. Routine evaluation of blood pressure, hematocrit, and glucose in newborns. Pediatrics 1993; 92: 47476. 4 Zubroe AB, Hulman S, Kushner H, Flakner B. Determinants of blood pressure in infants admitted to neonatal intensive care units: a prospective multicentre study. J. Perinatol. 2001; 21: 272 78. 5 Kent AL, Kecskes Z, Shadbolt B, Falk MC. Normative blood pressure data in the early neonatal period. Pediatr. Nephrol. 2007; 22: 133541. 6 Holland WW, Young IM. Neonatal blood pressure in relation to maturity, mode of delivery, and condition at birth. Br. Med. J. 1956; 2: 133133. 7 Engle WD. Denition of normal blood pressure range: the elusive target. In: Kleinman CS, Seri I (eds). Hemodynamics and Cardiology, Neonatology Questions and Controversies. Saunders Elsevier, New York, 2008; 3965. 8 Nwankwo MU, Lorenz JM, Gardiner JC. A standard protocol for blood pressure measurement in the newborn. Pediatrics 1997; 99: e10. 9 Park MK, Menard SM. Accuracy of blood pressure measurements by the Dinamap monitor in infants and children. Pediatrics 1987; 79: 90714. 10 Metcoff J. Clinical assessment of nutritional status at birth. Fetal malnutrition and SGA are not synonymous. Pediatr. Clin. North Am. 1994; 41: 87591. 11 Scott KK, Usher RH. Fetal malnutrition: its incidence causes and effects. Am. J. Obstet. Gynaecol. 1966; 94: 95163. 12 Ballard JL, Khoury JC, Wedig K, Wang L, Eilers-Walsman BL, Lipp R. New Ballard Score, expanded to include extremely premature infants. J. Pediatr. 1991; 119: 41723. 13 Lubchenco LO, Hansman C, Dressler M, Boyd E. Intrauterine growth as estimated from liveborn birth-weight data at 24 to 42 weeks of gestation. Pediatrics 1963; 32: 793800. 14 Jones JE, Jose PA. Neonatal blood pressure regulation. Semin. Perinatol. 2004; 28: 1418.

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73.00 73.00 73.00 92.00 87.60 86.10 88.00 82.00 82.00 74.00 3 4 6 13 87 148 101 49 9 4 34 35 36 37 38 39 40 41 42 43

WG

2011 The Authors Pediatrics International 2011 Japan Pediatric Society

34 35 36 37 38 39 40 41 42 43

10 12 21 34 125 161 139 35 14 7

SBP (mmHg) percentiles in vaginal delivery 47.00 47.00 47.00 65.00 73.00 73.00 57.00 57.00 58.00 66.00 72.50 73.00 49.00 49.00 50.50 64.50 70.00 73.00 48.00 50.40 60.00 66.00 72.50 84.40 39.20 46.00 57.00 66.00 74.00 83.00 43.90 50.00 59.25 67.50 75.00 79.00 47.20 53.00 62.00 67.00 72.50 81.00 46.50 49.00 57.00 64.00 72.50 80.00 37.00 37.00 61.00 71.00 74.50 82.00 53.00 53.00 55.50 67.00 73.25 74.00 SBP (mmHg) percentiles in cesarean section 37.00 37.60 43.00 54.50 63.25 88.60 38.00 42.20 55.00 60.50 70.75 86.30 44.30 47.60 50.00 56.00 61.50 74.60 37.25 39.50 53.75 60.00 71.25 80.50 46.00 48.00 53.00 60.00 68.00 74.00 43.00 47.00 57.00 63.00 69.00 78.80 45.00 48.00 55.00 63.00 72.00 81.00 39.20 47.00 61.00 66.00 69.00 76.80 42.00 49.50 59.75 64.00 66.50 72,.00 50.00 50.00 5200 55.00 73.00 87.00

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90.00 92.00 77.80 87.50 83.70 84.00 89.00 80.60 76.00 87.00

95th

Delivery room blood pressure of neonates

15 Earley A, Fayers P, Ng S, Shinebourne EA, De Swiet M. Blood pressure in the rst 6 weeks of life. Arch. Dis. Child. 1980; 55: 7557. 16 Youmbissi TJ, Oudou N, Mbede J, Nasah BT. Blood pressure proles of a group of African children in the rst year of life. J. Trop. Pediatr. 1989; 35: 2456. 17 De Swiet M, Fayers P, Shinebourn EA. Systolic blood survey in a population of newborn infants. Br. Med. J. 1976; 2: 911. 18 De Swiet M, Fayers P, Shinebourn EA. Systolic blood pressure in a population of infants in the rst year of life: the Brompton Study. Pediatrics 1980; 65: 102835. 19 Zubrow AB, Hulman S, Kushner H, Falkner B. Determinants of blood pressure in infants admitted to neonatal intensive care units: a prospective multicenter study. Philadelphia Neonatal Blood Pressure Study Group. J. Perinatol. 1995; 15: 4709. 20 Versmold HT, Kitterman JA, Phibbs RH, Gregory GA, Tooley WH. Aortic blood pressure during the rst 12 hours of life in infants with birth weight 610 to 4,220 grams. Pediatrics 1981; 67: 60713.

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21 Pejovic B, Peco-Antic A, Marinkovic-Eric J. Blood pressure in non-critically ill preterm and full-term neonates. Pediatr. Nephrol. 2007; 22: 24957. 22 Hegyi T, Carbone MT, Anwar M et al. Blood pressure ranges in premature infants. I. The rst hours of life. J. Pediatr. 1994; 124: 62733. 23 Emery EF, Greenough A, Yuksel B. Effect of gender on blood pressure levels of very low birthweight infants in the rst 48 hours of life. Early Hum. Dev. 1993; 31: 20916. 24 Sadoh WE, Ibhanesebhor SE. Oscillometric blood pressure reference values of African full-term neonates in their rst days postpartum. Cardiovasc. J. Afr. 2009; 20: 3447. 26 Adams MA, Pasternak JF, Kupfer BM, Gardner TH. A computerized system for continuous physiologic data collection and analysis: initial report on mean arterial blood pressure in very low-birth-weight infants. Pediatrics 1983; 71: 2330. 27 Spinazzola RM, Harper RG, de Soler M, Lesser M. Blood pressure values in 500- to 750-gram birthweight infants in the rst week of life. J. Perinatol. 1991; 11: 14751.

2011 The Authors Pediatrics International 2011 Japan Pediatric Society

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