BPs on an infant

I work peds and I've never seen a infant sized manual cuff. I can't imagine how you would hear anything. I would check the BP in an arm and a leg, make sure the child is calm, not moving, etc. If you think the child might be dehydrated look for other clinical clues like skin turgor, heart rate, UOP, cap refill, etc. These are things that are much more easily assessed in someone of that age.

I've been wondering about a situation that happened the other day, so I just wanted some feedback. Be gentle, I'm new to almost anything pediatrics! Just started in a pediatric floor this week! (I've been in a mostly adult ER for most of my career, so we don't see many peds bc we don't have a peds unit.)

Long story short, 2 week old with pyloric stenosis, scheduled for surgery later in the day. Had been NPO all day, however he hadnt been really eating for a few days due to the condition. He had a wet diaper at 0800, but when I checked him at 1230, he was bone dry. Got vitals, and the first time the BP looked low, so I rechecked it, and the second reading was high. This is with the automated cuff.

So, I know in the ER and with adults, at that point I would just get a good old fashioned manual reading so I could trust it. But how/where would u do that on an infant? Same way, just a smaller cuff? Can u actually hear anything with those tiny arteries?

Preceptor ended up calling the doc and baby got a bolus anyways, so the BP wasn't really an issue, but for the future, what do I do to know its accurate?

:)

Yes- you can do B.Ps on a baby's arm... just be sure the cuff is the right one (NiCU, neonatal, infant, and so on). And be sure the automated cuff has the parameters set for a baby- too much pressure could damage the kid, not just make it scream like bloody murder. Also, I found it helpful to carry a small reminder chart in my pocket thingy w/ages and expected vitals... if you type it in on your computer and print it off, you will have a smaller print than you can normally write....and I covered mine with clear packing tape to keep it usable longer. :)

Manual readings are possible.... think about infant CPR- you feel the brachial pulse. The biggest thing with the manual is having to deal with the cuff and stethoscope- and the squirming kid. I normally am not a huge fan of SOME automated B.Ps- but with a baby, you may get a more accurate one, since you're not adding to the kid's being upset by having to hold it down as much . JME. With a baby, they are going to get irritable w/BPs - so may want to wait a few minutes between them, to avoid the false highs.

If the BP is within the expected range for the age- or matches up with the reported or witnessed symptoms, that's about all you can do for accuracy....if the kid has a shrunken fontanel, but BP reads high, I'd question that big time. If the kid's fontanel is bulging and the BP is low- that could be REALLY bad. It's not just about the BP- especially with babies, who often don't get routine B.Ps with vs- sometimes on admission and prn- heart rate, rests, 02 sats, and temp are the most often done (at least when I worked peds a few years ago....B.Ps with every vs check was not done (your policy will tell you - or the individual doc- how they want it done).

Good question :)

My experience is NICU but we certainly deal with infants the same age as the one you were discussing.

We don't know any reliable way to auscultate a BP in an infant of that age. We must use automatic cuffs or arterial lines (not really an option in your case). The important thing is to make sure the BP cuff is properly sized to the infant, too small and one is likely to get too high of a reading, too large and the reading may be too low.

I have heard of doing a "flush" BP when one is in a tight spot or in primitive conditions. One attaches a manometer to a BP cuff, inflating it above what one suspects is the highest possible systolic, releasing very slowly while watching the lower part of the extremity for the "flush" of color indicating the return of arterial flow. This will only render a systolic pressure, which is not all that useful to us since our unit operates almost exclusively on mean BP's.

It is extremely hard to get a manuel, sure you can feel the brachial, but to hear it over a screaming baby is another game lol It is standard to get machine BP's on infants. If the diastolic was low, baby's tank was low, so the bolus was called for. A quick rule of thumb for newborns, with the mean arterial pressure, it should be around what their gestational age is, so if the baby is 37 weeks gestational, then the MAP should not be lower than 37. So your two week old full termer should have a MAP of about 40-44 for the lowest.

There are good guides for infant BP's out there too :)

You guys are all awesome!! These were such great answers.

NicuGal, LOVE the information about the MAP. I will have to do some research about that for sure.

Totally new to this world of infant/peds, have a ton to learn. Thanks for all the information! :)

ChristineN, you work in Peds but you've never seen an infant cuff? How on earth do you take accurate BPs on the babies?

One of the most important things when measuring BP is making sure you have an appropriately sized cuff. If the cuff is too big, the BP can be too low. Too small and it can read too high. This is a big deal in an infant when (at least in PICU) a high/low BP might mean titrating pressors or sedation and or giving/holding a bolus. You need to have the right sized cuff. As you learned in school, the cuff should cover 3/4 of the arm circumference.

If you have a generally healthy kid (like your pyloric stenosis pre-op), and your BP is off, the first thing you want to do is look at the child. Were they moving during the BP? Are they crying? If they are, your BP will probably be falsly high. is the BP cuff positioned correctly over the artery and was it applied snugly or loosely? A loose BP cuff will probably give you a low BP. If you can't detect anything wrong with the way the BP was taken, start assessing the child.

Some of the more common causes of high blood pressure in infants, who aren't on any meds) are pain and fluid overload. You should be learning the FLACC scale for measuring pain in infants. Also assess for anything that might be causing the baby pain- check the IV sites, check for toys or other objects in the bed that might be pinching the baby. Check for wrinkles in the bedding and make sure the baby isn't laying on anything. Check for signs of overhydration- bulgind fontanels, peri orbital edema, peripheral edema, etc.

The biggest reason for low BP in an otherwise healthy kid is dehydration. So do your assessment for hydration- sunken fontanels, poor cap refill, tachycardia, tachypnea, poor skin turgur, sunken eyes, etc.

If you do all that and you still can't find anything that would be affecting the blood pressure, it's time to let the doctor know.

I started in PICU a month ago. It's a huge learning curve, but if you are interested, ask questions, get involved in anything interesting (even if it's not your patient), and ask if you can help, you'll learn quickly. Keep your eyes and ears out for things going on that you can do or get involved with. I've put in two NGs and a Foley in an infant just because I asked if I could. :)

She said a manual infant cuff. I'm sure they have the automated ones. We only have adult manual cuffs in our ED ... hmmmm, something to think about getting....

My mistake. Thank you for clarifying.

So do your facilities not do manuals on infants? All of our cuffs are detachable and come in various sizes so we can switch from automatic to manual without a problem.

My apologies if I'm misunderstanding - the coffee hasn't kicked in yet lol

We only use auto cuffs on the babies, but we treat less by the BP and more by clinical signs. We'll get a specific gravity q4h, check cap refill, pulses, look for tachycardia and increased WOB, and watch the fontanel (a sunken fontanel is a sign of profound dehydration). You can't really go by MAP in neonates and young infants who are squirmy and all over the place. You'll get a MAP of 37 for one reading and 82 for another!

If we have to do a manual on a baby we use a doppler, impossible to hear with a stethoscope. However, we very rarely do manuals at all. If we get an 'off' reading I often leave the cuff on and dinamap attached, swaddle the baby up and leave it for 5mins to settle, then creep in and hit 'go' again!! haha.

I've been wondering about a situation that happened the other day, so I just wanted some feedback. Be gentle, I'm new to almost anything pediatrics! Just started in a pediatric floor this week! (I've been in a mostly adult ER for most of my career, so we don't see many peds bc we don't have a peds unit.)

Long story short, 2 week old with pyloric stenosis, scheduled for surgery later in the day. Had been NPO all day, however he hadnt been really eating for a few days due to the condition. He had a wet diaper at 0800, but when I checked him at 1230, he was bone dry. Got vitals, and the first time the BP looked low, so I rechecked it, and the second reading was high. This is with the automated cuff.

So, I know in the ER and with adults, at that point I would just get a good old fashioned manual reading so I could trust it. But how/where would u do that on an infant? Same way, just a smaller cuff? Can u actually hear anything with those tiny arteries?

Preceptor ended up calling the doc and baby got a bolus anyways, so the BP wasn't really an issue, but for the future, what do I do to know its accurate?

Hi! I work in pediatric cardiology and it is possible to get an infants blood pressure manually. The first step is to make sure you have the right size cuff. Also, the stethoscope I use is shaped in a way that I've found fits underneath the cuff a bit. I always palpate for the brachial pulse first so I can put my stethoscope right over it. If you find you can't hear it at all, you can do a palpated blood pressure: Feel for the brachial pulse, pump up the cuff until it goes away, release, and feel for when the pulse returns. You will only get the systolic pressure but it's very accurate! If you can't even feel the pulse, this is when a doppler is needed. I always go for the doppler last because it requires two people (one to hold the doppler in place and one to pump the cuff).

And of course, all this can be challenging with a fussy baby! With a little practice you'll be able to get them on almost any baby. :)