Normal Pediatric Vital Signs
Infants and children require age-specific vital sign assessment with temperature, heart rate, and respiratory rate documented at every encounter, while blood pressure and pulse oximetry should be available based on illness severity. 1
Core Vital Sign Requirements
All pediatric patients must have a complete set of vital signs recorded including:
- Temperature 1
- Heart rate (pulse rate) 1, 2
- Respiratory rate 1, 2
- Blood pressure and pulse oximetry available for all ages based on clinical severity 1, 2
A formal process must identify abnormal vital signs according to patient age and notify the physician of abnormal values. 1, 2
Heart Rate Parameters by Age
Age-specific heart rate ranges based on evidence-derived centiles:
- Neonates (first week): 91-166 bpm 2
- 7-30 days: 107-182 bpm 2
- 1-3 months: 121-179 bpm 2
- 1 month peak: Median reaches maximum of 145 bpm 3
- 2 years: Decreases to median 113 bpm 3
The median heart rate increases from 127 bpm at birth to 145 bpm at approximately 1 month, then progressively declines through early childhood. 3
Critical threshold: Heart rate <60 bpm with signs of poor perfusion requires immediate CPR and chest compressions, as cardiac arrest is imminent. 2
Respiratory Rate Parameters
Respiratory rate shows steep decline from birth through age 2 years:
- Birth: Median 44 breaths per minute 3
- 2 years: Median 26 breaths per minute 3
- Early adolescence: Continues gradual decline 3
The steepest fall in respiratory rate occurs in infants under 2 years of age. 3
For rescue breathing: Provide 1 breath every 2-3 seconds (20-30 breaths per minute) if pulse is present but breathing is absent or inadequate. 2
Blood Pressure Guidelines
Hypertension is defined as systolic or diastolic blood pressure at or above the 95th percentile for age, height, and sex. 2
Blood pressure should be measured after 5 minutes of rest, with the patient seated and right arm supported at heart level. 2
For children <12 years: Use Pediatric Advanced Life Support definitions, which align best with population-based lower centiles. 2
For children >12 years: Parshuram's early warning score cut-offs agree better with the 5th percentile. 2
Hypotension with capillary refill >3 seconds indicates more severe shock than isolated tachycardia. 2
Critical Clinical Pitfalls to Avoid
Do not misinterpret transient bradycardia during feeding, sleep, or defecation as pathological - these represent normal vagal tone increases. 2
Altered mental status, poor peripheral perfusion, or weak pulses warrant immediate evaluation regardless of specific vital sign values. 2
Persistent tachycardia or bradycardia requires investigation for underlying causes. 2
Abnormal heart rates below the lower normal limit (e.g., <107 bpm in infants 7-30 days) or above the upper normal limit (e.g., >182 bpm in infants 7-30 days) may indicate CNS abnormalities, hypothermia, or hyperthyroidism. 2
Documentation Requirements
Weight must be documented in kilograms (except for children requiring emergent stabilization) and recorded prominently with vital signs. 1, 2
For children requiring resuscitation or emergency stabilization, use a standard method for estimating weight in kilograms (e.g., length-based system). 1
Vital signs must be documented at regular intervals with age-appropriate reference ranges readily available. 1
Important Limitations of Current Reference Ranges
Current published reference ranges show striking disagreement with evidence-based centile charts, with limits frequently exceeding the 99th and 1st centiles or crossing the median. 3
Empirically derived centiles from real-world emergency department encounters identify a higher proportion of children requiring interventions compared to traditional Pediatric Advanced Life Support criteria. 4, 5
Traditional vital sign ranges derived from healthy children have limited utility in identifying children with serious illness requiring immediate intervention. 5