Continuing Medical Education Article

Analysis of the evidence for the lower limit of systolic and mean
arterial pressure in children
Ikram U. Haque, MD, FAAP; Arno L. Zaritsky, MD, FAAP, FCCM

LEARNING OBJECTIVES
On completion of this article, the reader should be able to:
1. Identify key factors that contribute to determining the optimal blood pressure goals for resuscitation of critically ill children.
2. Select appropriate blood pressure targets in critically ill children.
3. Recall the relationship between systolic, diastolic, and mean arterial blood pressure.
Both authors have disclosed that they have no financial relationships with or interests in any commercial companies
pertaining to this educational activity.
Lippincott CME Institute, Inc., has identified and resolved all faculty conflicts of interest regarding this educational activity.
Visit the Pediatric Critical Care Medicine Web site (www.pccmjournal.org) for information on obtaining continuing medical
education credit.

Objective: Systolic blood pressure (SBP) and mean arterial pres-
sure (MAP) are essential evaluation elements in ill children, but there
is wide variation among different sources defining systolic hypoten-
sion in children, and there are no normal reference values for MAP.
Our goal was to calculate the 5th percentile SBP and MAP values in
children from recently updated data published by the task force
working group of the National High Blood Pressure Education Pro-
gram and compare these values with the lowest limit of acceptable
SBP and MAP defined by different sources.
Design: Mathematical analysis of clinical database.
Methods: The 50th and 95th percentile SBP values from task
force data were used to derive the 5th percentile value for children
from 1 to 17 yrs of age stratified by height percentiles. MAP values
were calculated using a standard mathematical formula. Calculated
SBP values were compared with systolic hypotension definitions
from other sources. Linear regression analysis was applied to create
simple formulas to estimate 5th percentile SBP and 5th and 50th
percentile MAP for different age groups at the 50th height percentile.
Results: A 9 –21% range in both SBP and MAP values was
noted for different height percentiles in the same age groups. The
5th percentile SBP values used to define hypotension by different
sources are higher than our calculated values in children but are
lower than our calculated values in adolescents. Clinical formulas
for calculation of SBP and MAP (mm Hg) in normal children are as
follows: SBP (5th percentile at 50th height percentile) ⴝ 2 ⴛ age
in years ⴙ 65, MAP (5th percentile at 50th height percentile) ⴝ
1.5 ⴛ age in years ⴙ 40, and MAP (50th percentile at 50th height
percentile) ⴝ 1.5 ⴛ age in years ⴙ 55.
Conclusion: We developed new estimates for values of 5th
percentile SBP and created a table of normal MAP values for
reference. SBP is significantly affected by height, which has not
been considered previously. Although the estimated lower limits
of SBP are lower than currently used to define hypotension, these
values are derived from normal healthy children and are likely not
appropriate for critically ill children. Our data suggest that the
current values for hypotension are not evidence-based and may
need to be adjusted for patient height and, most important, for
clinical condition. Specifically, we suggest that the definition of
hypotension derived from normal children should not be used to
define the SBP goal; a higher target SBP is likely appropriate in
many critically ill and injured children. Further studies are needed
to evaluate the appropriate threshold values of SBP for determin-
ing hypotension. (Pediatr Crit Care Med 2007; 8:138 –144)
KEY WORDS: blood pressure; hypotension; infant; child

M onitoring blood pressure in
critically ill or injured chil-
dren is considered one of
the mainstays for patient
evaluation in the prehospital setting, pe-
Assistant Professor (IUH), Professor and Chief
(ALZ), Division of Pediatric Critical Care Medicine, De-
partment of Pediatrics, University of Florida College of
Medicine, Gainesville, FL.
diatric emergency department, and in-
tensive care unit (1–5). Studies in adults
and children with trauma showed that
systolic blood pressure (SBP) is a predic-
tor of mortality (6) and that prehospital
Copyright © 2007 by the Society of Critical Care
Medicine and the World Federation of Pediatric Inten-
sive and Critical Care Societies
DOI: 10.1097/01.PCC.0000257039.32593.DC
hypotension is associated with an in-
creased risk of mortality (7–10). The
depth and duration of hypotension appear
to have a direct relationship with adverse
hospital outcome in emergency depart-
ment patients with nontraumatic shock
(11). Moreover, hypotension is used as a
criterion for diagnosis of “decompen-
sated” shock along with other features of
poor perfusion in pediatric patients (1, 3).
Most published guidelines define hypo-

138 Pediatr Crit Care Med 2007 Vol. 8, No. 2

tension in children as an SBP below the
5th percentile for age. Table 1 is a sum-
mary of SBP values as used by the Pedi-
atric Advanced Life Support (PALS)
course, Brain Trauma Foundation (BTF),
and International Pediatric Sepsis Con-
sensus Conference to define hypotension
in children. These guidelines for hypo-
tension are reportedly derived from the
reports of the task force on blood pres-
sure control in normal healthy children
(12, 13). Although age-related “norms” of
blood pressure are published in most of
the relevant pediatric emergency and
critical care training manuals and text-
books, the evidence for these norms is
usually not referenced and the publica-
tions do not report the confidence inter-
vals for normal blood pressure or adjust-
ments of these norms for gender or for
height and weight of the child within an
age group. Variation in the age-based
range of blood pressure was observed in
the recently published international con-
sensus conference definitions of sepsis
and organ dysfunction in children, which
included a table of the lower limits of
acceptable SBP (14). These guidelines re-
portedly were based on a review of pub-
lished studies but appear to overestimate
the lower limits of SBP in different aged
children, as shown in Table 1.
Hemodynamic treatment of shock is
aimed at maintaining oxygen delivery
above a critical threshold and increasing
mean arterial pressure (MAP) to a level
that allows appropriate distribution of
cardiac output for adequate tissue perfu-
sion (15). In adults, a MAP range from 60
to 90 mm Hg has been used as the desired
target (16 –19) for therapeutic end points
such as improved urine output and cre-
atinine clearance (20). In children, sev-
eral sources recommend early aggressive
restoration of hemodynamic end points,
Table 1. Definition of hypotension in children by different sources
Hypotension Guidelines, mm Hg
Pediatric Advanced Life
Age Group Support
0 days–1 wk ⬍60
1 week–1 mo ⬍60
1 mo–1 yr ⬍70
⬎1–5 yrs 70 ⫹ 2 ⫻ yrs
6–12 yrs 70 ⫹ 2 ⫻ yrs (up to 10 yrs)
⬍90 (⬎10 yrs)
13–18 yrs ⬍90
a
Brain Trauma Foundation last accessed October 14, 2005 (http://www2.braintrauma.org/
guidelines/downloads/btf_guidelines_prehospital.pdf); b corrected values, letter to the editor, Gold-
stein et al. Pediatr Crit Care Med 2005; 6:500 –501.
Pediatr Crit Care Med 2007 Vol. 8, No. 2
which include normalization of MAP to
age-appropriate values in pediatric shock
states (1, 3, 21–23). Unfortunately, there is
little objective evidence defining the target
values of MAP in pediatric patients. Fur-
thermore, no age-related MAP nomogram
in children is available for clinicians to use
as a reference. Neonatal studies have col-
lected data on the normal values of blood
pressure in very low birth weight infants
(24 –26), but there are no pediatric studies
of MAP from children in the pediatric in-
tensive care unit. When mathematical in-
tegration of invasive arterial pressure mea-
surements to calculate the MAP is not
available, MAP is typically calculated by us-
ing the following formula, which assumes
that one third of the cardiac cycle is spent
in systole (27–29):
MAP ⫽ diastolic pressure
⫹ ([systolic pressure
⫺ diastolic pressure]/3) [1]
The aim of this study was to use a
large published database of blood pres-
sures in children to estimate the lower
limits of systolic pressure and define nor-
mal mean arterial pressures using the
preceding equation and to compare these
estimates with those that are currently
being used. To achieve our aim, we used
data from the working group of the Na-
tional High Blood Pressure Education
Programs, which recently published up-
dated guidelines on the diagnosis, evalu-
ation, and treatment of high blood pres-
sure in children and adolescents (30). We
analyzed the data from this report using
standard mathematical models to calcu-
late the 5th percentile values of SBP and
diastolic blood pressure for the entire pe-
diatric population.
Brain Trauma International Pediatric Sepsis
Foundationa Consensus Conferenceb
⬍65 ⬍59
⬍65 ⬍79
⬍65 ⬍75
⬍70–75 ⬍74
⬍80–90 ⬍83
⬍90 ⬍90
MATERIALS AND METHODS
The updated blood pressure report is based
largely on data collected by the National Cen-
ter for Health Statistics with ⬎32,000 boys
and ⬎31,000 girls including new data from
the 1999 –2000 National Health and Nutrition
Examination Survey. The blood pressures re-
ported by the task force were obtained by
auscultatory method in normal healthy chil-
dren. The revised blood pressure tables now
include the 50th, 90th, 95th, and 99th percen-
tiles by gender, age, and height. The values for
50th percentile and 95th percentile of SBP and
diastolic blood pressure were extracted from
the task force data for all age groups across the
range of height percentiles into tables for both
boys and girls (30). We used simple mathemat-
ical calculations to derive the 5th percentile
values of SBP from these data, assuming that
the data in this large database are normally
distributed so that the difference in pressure
between the 95th and 50th percentile should
be the same as the difference between the 5th
percentile and 50th percentile. Tables for val-
ues of the 5th percentile SBP for different
ages, genders, and height percentiles were
generated. We then compared calculated val-
ues of SBP with currently used guidelines for
defining hypotension from different sources.
The published data and our calculated val-
ues of SBP and diastolic pressure at various
percentiles of height for a given age were then
used to estimate the MAPs for age, gender, and
height percentile using the previously stated
formula. We then used linear regression to
determine the line of best fit and from that
regression created simple mathematical for-
mulas for clinicians to approximate values of
the 5th percentile SBP and 5th and 50th per-
centile for MAP at the 50th height percentile
for children 1–17 yrs of age. We also calculated
the effect of height on the range of SBP values
and derived simple estimates to adjust the SBP
according to the height percentile.
RESULTS
The demographic information on the
source of blood pressure data of the pop-
ulation was described in detail in the
original report (30). Table 2 shows the 5th
percentile values of SBP from age 1–18
yrs for males and females; the table also
details the range of SBP for each age
group ranging from the 5th percentile to
95th percentile for height. As seen in this
table, the SBP in the same age group
varies by approximately 8 –9 mm Hg be-
tween the 5th and 95th height percentile
in males and by approximately 6 –7 mm
Hg in females. Relative to the mean SBP,
the magnitude of the difference between
the 5th and 95th height percentile com-
139
Table 2. Calculated 5th percentile systolic blood pressure (mm Hg) according to height percentiles olescents exceed the 90 mm Hg threshold
among boys (M) and girls (F) 1–18 yrs old for lower limit of acceptable blood pres-
sure recommended in the PALS and Ad-
Fifth Percentile Systolic Blood Pressure, Percentile for Height
vanced Cardiac Life Support courses for
5th 25th 50th 75th 95th adolescents.

Age, Yrs M F M F M F M F M F
DISCUSSION
1 62 66 65 68 67 68 70 71 72 73
2 67 68 70 70 70 71 72 71 74 73 The early detection and rapid treat-
3 68 68 71 71 73 71 76 74 77 76 ment of hypotension are important in
4 70 71 73 73 75 74 78 74 79 76
the management of critically ill and in-
5 72 71 76 74 78 76 78 77 80 79
6 73 74 76 76 78 77 81 79 83 81 jured children. Moreover, MAP is often
7 74 76 77 78 79 79 81 79 83 82 used as a therapeutic end point in shock
8 77 78 80 78 82 81 82 82 84 84 management. Thus, it is important to
9 77 78 80 81 82 83 85 84 87 86 define the normal ranges for both vari-
10 79 80 83 83 85 85 85 86 89 88
11 81 82 85 85 87 85 87 88 89 90 ables in children. These normal values
12 83 85 86 87 89 87 91 90 93 92 represent a starting point for thinking
13 87 87 88 89 90 90 92 92 94 92 about the desired blood pressure target,
14 88 89 91 89 94 92 96 93 98 95 but the desired target blood pressure in
15 92 90 95 92 95 93 97 93 99 95
16 93 91 96 93 98 93 101 96 103 98 a critically ill or injured child is likely
17 97 91 98 93 100 93 102 96 104 98 higher than these lower limits of nor-
mal blood pressure obtained in healthy
children.
pared with the 50th height percentile and were chosen because they are easier Although not evidence based, hypo-
SBP by age was 7–14.9% in boys and to recall. tension is typically defined as an SBP
5.4 –11.1% in females. This variation is less than the 5th percentile for age.
seen graphically in Figure 1. SBP (5th percentile at 50th height Since it is often difficult to recall blood
The calculated values for MAP at the pressure data listed in tables by age,
percentile) ⫽ 2 ⫻ age in years ⫹ 65 various formulas have been used to es-
5th, 50th, and 95th percentiles stratified
by different height percentiles in the [2] timate the lower limit of acceptable
same age group are shown in Table 3. A blood pressure. For example, the for-
difference of approximately 5– 6 mm Hg SBP (50th percentile at 50th height mula used in PALS training materials
is noted between 5th and 95th height (1) states that the lower limit of accept-
percentile) ⫽ 2 ⫻ age in years ⫹ 85 able SBP is 70 ⫹ 2 ⫻ (age in years) for
percentiles for the same age group in
both males and females. This results in a [3] children from 1 to 10 yrs of age. For
range of MAP across different heights of children ⬍1 yr, the lowest acceptable
8 –13% in girls and 9 –21% in boys. There MAP (5th percentile at 50th height SBP is 60 mm Hg up to 1 month and 70
is wide variation, however, in the normal mm Hg from 1 month to 1 yr. For
percentile) ⫽ 1.5 ⫻ age in years children ⬎10 yrs of age, the lowest ac-
MAP values across the 5th and 95th per-
centiles for a given height. ⫹ 40 [4] ceptable SBP is 90 mm Hg; the latter is
Linear regression was applied to the consistent with Advanced Cardiac Life
50th height percentile group for the 5th MAP (50th percentile at 50th height Support guidelines for defining hypo-
and 50th percentile values of SBP and the tension in adults (31). A review of dif-
percentile) ⫽ 1.5 ⫻ age in years ferent sources revealed substantial vari-
5th and 50th percentile MAP (data not
shown). Simplified formulas for estimat- ⫹ 55 [5] ation in their definition of systolic
ing the 5th percentile SBP and the 5th hypotension, and current sources do
and 50th percentile MAP for 50th percen- The 5th percentile SBPs are plotted as not consider the variation in blood
tile of height were derived from these shown in Figure 1 for both males and pressure due to height differences
values, as shown next. A simple calcula- females along with the PALS, Brain within an age group. Analysis of our
tion can be used to estimate 5th percen- Trauma Foundation, and International derived data from the updated blood
tile SBP adjusted for height percentile for Pediatric Sepsis Consensus Conference pressure data from the task force report
each quartile above or below 50th height definitions and our estimated formulas does not agree with any of the recom-
percentile. Our calculations suggest that for SBP determined from regression anal- mended threshold blood pressures to de-
for males ⫾2 mm Hg for each height ysis. The graph shows that systolic blood fine hypotension, making it difficult for the
quartile and for females ⫾1.5 mm Hg for pressure limits defined by both PALS and clinician to know which source to use and
each quartile of height can approximate Brain Trauma Foundation are high com- remember. Furthermore, it is interesting
the 25th to 75th percentile SBP values. pared with our calculated values, and the to note that the threshold blood pressure
The line of best fit for MAP was exponen- PALS limit often exceeds the 5th percen- values used in the Paediatric Logistic Or-
tial, but the linear equations produce es- tile SBP even in children at the 95th gan Dysfunction score are much higher
timates that are within the range of val- percentile of height. Moreover, the graph than any of the current threshold blood
ues across the range of height percentiles illustrates that most normal healthy ad- pressure values that define hypotension

140 Pediatr Crit Care Med 2007 Vol. 8, No. 2

Figure 1. Fifth percentile systolic blood pressure (BP) according to height (HT) percentiles plotted against Pediatric Advanced Life Support (PALS), Brain
Trauma Foundation (Brain Trauma), and International Pediatric Sepsis Consensus Conference (Int Ped Sepsis) hypotension guidelines, and our new
estimates based on linear regression R2 for boys ⫽ .99 (top) and for girls ⫽ .98 (bottom). Gray lines and the shaded area indicate the calculated values.

Pediatr Crit Care Med 2007 Vol. 8, No. 2 141

Table 3. Calculated mean arterial blood pressure (mm Hg) according to height percentiles among boys (M) and girls (F) 1–18 yrs old

Mean Arterial Blood Pressure for Boys and Girls, Percentile for Height

Percentile 5th 25th 50th 75th 95th

for Blood
Age, Yrs Pressure M F M F M F M F M F

1 5 30 35 33 37 34 37 36 39 37 40
50 49 53 52 54 53 55 54 57 56 58
95 69 71 70 72 72 73 73 74 74 76
2 5 35 39 38 41 39 42 40 42 41 44
50 54 57 56 58 57 59 59 60 60 62
95 73 75 75 76 76 77 77 78 79 80
3 5 39 42 41 44 42 44 44 46 45 47
50 58 60 60 61 61 62 62 64 64 65
95 77 78 78 79 80 80 81 81 82 83
4 5 42 45 43 46 46 47 47 47 48 49
50 61 63 63 64 64 65 66 65 67 67
95 79 80 82 82 83 83 84 84 86 85
5 5 45 46 47 48 49 49 49 50 51 52
50 63 64 66 66 67 67 68 68 69 69
95 82 82 84 83 85 85 87 86 88 87
6 5 47 49 49 50 50 51 52 52 53 54
50 66 66 67 68 69 69 70 69 71 71
95 84 84 86 85 87 86 88 87 90 89
7 5 51 50 50 51 52 52 53 53 54 55
50 67 68 69 69 70 70 72 71 73 72
95 83 85 88 87 89 88 90 89 92 90
8 5 50 52 53 52 54 54 55 55 56 56
50 69 70 71 70 72 71 73 72 75 74
95 87 87 89 88 91 89 92 90 93 91
9 5 51 53 53 54 55 55 56 56 58 57
50 70 71 72 71 73 73 75 74 76 75
95 88 89 91 89 92 90 93 91 94 93
10 5 52 54 55 55 56 56 56 57 59 59
50 71 72 73 73 75 74 75 75 77 76
95 90 90 92 90 93 92 94 93 96 94
11 5 54 55 56 56 57 57 58 59 59 60
50 72 73 74 74 75 75 76 76 78 78
95 91 91 92 92 94 93 95 94 96 95
12 5 54 57 57 58 58 58 60 60 61 61
50 73 75 75 75 77 76 78 78 79 79
95 92 92 94 93 95 94 96 95 98 97
13 5 56 58 57 59 59 60 60 61 61 62
50 75 76 76 77 77 78 79 79 80 80
95 93 94 95 94 96 95 97 97 99 98
14 5 59 60 59 60 61 61 62 62 63 64
50 75 77 78 78 79 79 80 80 82 81
95 91 95 96 96 97 97 99 98 100 99
15 5 58 61 61 61 62 62 63 63 64 64
50 77 78 79 79 80 80 82 81 83 82
95 96 96 98 97 99 98 100 99 102 100
16 5 60 61 62 62 63 63 65 63 66 66
50 79 79 81 80 82 81 83 82 85 84
95 98 96 99 98 101 99 102 100 104 101
17 5 63 61 63 62 65 63 67 65 69 66
50 81 79 83 80 84 81 85 82 87 84
95 100 96 102 98 103 99 104 100 106 101

(32). These empirically derived blood pres-
sure values suggest that our current
thresholds are too low.
Our study analyzed a large database of
blood pressures in children to provide
objective evidence for the lowest accept-
able SBP and MAP. Our data show that
the definition of the 5th percentile SBP
from all the currently used sources is
often higher than the values calculated
based on the largest available database of
blood pressure in children. Using a re-
gression model, we developed new simple
formulas that give a more accurate ap-
proximation of 5th percentile SBP for dif-
ferent age groups in normal children
from 1 to 17 yrs of age:
SBP (5th percentile at 50th height
percentile) ⫽ 2 ⫻ age in years ⫹ 65
[6]
It is important for clinicians to know
that there is a fairly large difference on a
percentile basis between the lower limit
of SBP for a short vs. a tall child. This
variation has not previously been reported
or used to adjust the goal for assessment or
blood pressure target. We do not know the
clinical or pathophysiologic significance of
this observation. The estimated SBP for
25th and 75th percentile height children at
a given age can be estimated by adding or

142 Pediatr Crit Care Med 2007 Vol. 8, No. 2

subtracting 2 mm Hg for boys and 1.5 mm
Hg for girls from the SBP estimate at the
50th percentile of height.
Another important finding was that al-
though the adult Advanced Cardiac Life
Support guideline for hypotension uses 90
mm Hg beyond 12 yrs of age, the 5th per-
centile values for SBP in normal children
in this age group were ⬎90 mm Hg. The
clinical implication of this is not clear ex-
cept that it suggests that clinicians may be
accepting a lower SBP than appropriate.
Moreover, using the lower limit of SBP as
the definition of decompensated shock and
hypotension and especially as the target for
resuscitation may not be appropriate since
these definitions are based on data in nor-
mal children and do not account for the
stress response that occurs in seriously ill
or injured children. For example, in a re-
cent study, Dark et al. (33) followed a co-
hort of children admitted to the emergency
department with blunt trauma and found
that these patients presented with relative
systolic hypertension compared with age-
appropriate SBP as estimated by the guide-
lines. They speculated that apparently nor-
mal blood pressure in children with blunt
trauma could represent relative hypoten-
sion. Another study evaluated the relation-
ship between blood pressures and outcome
after severe traumatic brain injury in pedi-
atric patients (34). Poor outcome was asso-
ciated with an SBP less than the age-
adjusted 75th percentile even if the SBP
was ⱖ90 mm Hg. White et al. (35) reported
that the odds of survival increased 19-fold
in pediatric severe traumatic brain injury
patients with maximum SBP of ⬎135 mm
Hg, also suggesting that supranormal
blood pressures are associated with im-
proved outcome in this patient population.
These studies highlight that a higher SBP
target may be particularly important in
children with traumatic brain injury in
whom cerebral perfusion is determined, in
part, by maintenance of an adequate perfu-
sion pressure when intracranial pressure is
increased. It is noteworthy, however, that
the Brain Trauma Foundation still uses an
SBP ⬍90 mm Hg to define hypotension in
adolescents even though a much higher
SBP is needed to maintain cerebral perfu-
sion pressure ⬎70 mm Hg if one assumes
that intracranial pressure is 20 mm Hg.
Since one of the major determinants
of tissue perfusion pressure is MAP, it is
typically used in shock states to estimate
tissue perfusion pressure and thus blood
flow. For example, cerebral perfusion
pressure (CPP) is calculated by the fol-
lowing formula (36):
Pediatr Crit Care Med 2007 Vol. 8, No. 2
CPP ⫽ mean arterial pressure
⫺ intracranial pressure [7]
Hence, it is important for clinicians
caring for critically ill children to know
whether a child’s MAP is appropriate for
his or her age. We calculated the values of
MAP tabulated according to height per-
centile for different age groups. The op-
timal MAP to achieve adequate tissue per-
fusion pressure in shock is unknown and
likely varies according to the type of
shock. As noted, a higher MAP is likely
needed in children with increased intra-
cranial pressure. Conversely, in a child
with cardiogenic shock treated with va-
sodilators, adequate tissue perfusion and
improved myocardial performance may
be achieved at a low MAP by maximizing
vasodilator therapy since blood flow is
proportional to MAP ⫼ systemic vascular
resistance. As a starting estimate of ade-
quate perfusion pressure, it may be ap-
propriate to choose the 50th percentile
MAP for age and height as a target based
on the preceding observations that criti-
cally ill children often have elevated
blood pressures. Using regression analy-
sis, we created a formula that approxi-
mates the MAP for age in both males and
females:
MAP (5th percentile at 50th height
percentile) ⫽ 1.5 ⫻ age in years
⫹ 40 [8]
MAP (50th percentile at 50th height
percentile) ⫽ 1.5 ⫻ age in years
⫹ 55 [9]
Clinicians should recall that MAP val-
ues vary across the height percentile
within the same age group, and this vari-
ation may need to be considered when
caring for a very short or tall child.
CONCLUSIONS
We developed new estimates of the
fifth percentile SBP for children 1–17 yrs
of age from analysis of recently published
blood pressure data from the Task Force
on Hypertension. Most of the current
guidelines use higher values for defining
hypotension compared with our estimate
from a large pediatric blood pressure da-
tabase. Since the “normal” blood pres-
sures are obtained from healthy children
at rest, it is rational to use a higher
threshold for defining hypotension in
critically ill children than currently used.
Furthermore, since there is a 5–15%
variation in normal SBP from the 5th to
95th percentile height, the clinician may
need to consider using a length-based
system for determining the appropriate
blood pressure target. Moreover, the cli-
nician should recognize that automated
blood pressure devices are not reliable
when distal pulses are weak to absent,
and other signs of poor perfusion should
be used to define severe shock besides
just a low SBP.
Clearly, there is a critical need for
studies to validate the appropriate blood
pressure target and to better define hypo-
tension in critically ill children. To avoid
confusion among pediatric healthcare
providers, we recommend using a consis-
tent definition of hypotension by all pro-
fessional groups developing guidelines
for children. This consistent definition of
hypotension, however, should not repre-
sent the target blood pressure goal. In-
stead, we recommend that the target
blood pressure goal should be individu-
ally developed based on adequacy of or-
gan perfusion measured by markers of
tissue perfusion such as lactate and urine
output and considering the etiology of
the shock state. For example, epidemio-
logic studies in trauma patients suggest
that a higher blood pressure target is
appropriate, but this has not been tested
prospectively. We also calculated normal
values for MAP to be used as reference
values while treating critically ill chil-
dren. Further research is needed to iden-
tify appropriate SBP and MAP treatment
goals in populations of critically ill and
injured children, such as children with
traumatic brain injury, to better deter-
mine the optimal therapeutic end point.
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