Heart Rate and Blood Pressure in Black Newborns and in White Newborns

(1)

EXPERIENCE

AND

REASON-Briefly

Recorded

‘In Medicine one must pay attention not to platIsil)le theorizing i)IIt to experience and rcaon together. .. .I agree that theorizing is to he approved, provi(le(l that it is based on facts, and systematically makes its deductions from what is observed. . ..But conclusions drawn

from unaided reason can hardly be serviceai)le; only those drawn from observed fact. Hippocrates: Precepts. (Short communications of factual ,iu,ter,al are pul)hIhed here. Co:nmeiits (171(1criticisms appear as Letters to the Editor.)

Heart

Rate and Blood Pressure

in Black

Newborns

and in White

Newborns

While studying the reactivity to auditory

stimuli

of newborns

of schizophrenic

parents

and

of

controls

among

a

low

socioeconomic

class

urban

population,

we

noted

that,

regardless

of a

family history of mental illness,

black

newborns

had

higher

heart

rate

levels

during

sleep

than

white

l

The

present

study

aimed

to

determine

if the

racial heart rate difference in newborns was

present

in a randomly

selected

group,

as well

as in

those selected in relation to a family history of mental illness when tested under nonstimulus rather than stimulus conditions.

The

possibility

of

a racial blood pressure difference at birth was also

examined.

SUBJECTS AND METHOD

A total of 74 white and 67 black, randomly

selected

subjects

born

to low

socioeconomic

class

women from a prenatal clinic at a large academic

hospital

were

tested.

Fifty

percent

of the

women

and 38% of their spouses had completed no more

than

the

10th

or

1 ith

grades.

Fifty

percent

received public assistance. Written, informed

consent was

obtained

from

the

parents

who

were

invited

to

observe

the

measurement

if

they

wished.

The subjects were full-term newborns above

the

tenth

percentile

in weight

for

gestational

age

who

were

healthy

upon

physical

examination

and

showed

no evidence

of heart

disease.

Each

subject

was

tested

after

the

9:00

AM feeding on the third

postnatal

day

(60

± 12 hours) as previously

described.’ Electrodes were applied and the

subject

was

swaddled,

supine,

for

a

3#{189}-hour

interfeeding period. Heart rate and

blood

pres-sure were nieasured at ambient temperature 24.5

C

(

± 1.1) with no stimuli presented, during

periods

of quiet,

non-REM

sleep

only.

HEART RATE MEASUREMENT AND RELIABILITY

The heart period, which is the duration in milliseconds of the interval between the R-waves

of the ECG, was monitored continuously. The

average

heart

period

was

calculated

for

each

liOn-REM

period

of at least

four

minutes’

duration,

on

the

basis

of approximately

40 intervals

between

the

R-waves

of the

electrocardiograph.

Since

the

average

heart

period

diminished

significantly

in

successive non-REM periods,2. .;

and

the

number

of non-REM

periods

in a test session

varied

from

one

to

six (the

number

did

not

differ

in

the

two

racial

groups),

three

measures

of

heart

period

were

calculated:

(1)

the

longest

of

the

average

heart

periods

(slowest

heart

rate)

of the

non-REM

periods

in a session;

(2) the

average

heart

period

of the

first

non-REM

period;

and

(3) the

mean

of

the

average

heart

periods

for

all

non-REM

periods

in a session. The longest average heart period correlated r = .88 with the average heart

period for the first non-REM period and r = .97

with

the

mean

of all

the

average

heart

periods.

Both the longest average heart period (slowest heart rate) and the mean of all the average heart

periods

were

more

reliable

than

the

average

heart

period

for

the

first non-REM

period

on

retesting

(2)

284

HEART

RATE

IN NEWBORNS

TABLE I

HEART RATE DURING NON-REM SLEEP IN BLACK

NEWBORNS AND WHITE NEWBORNS

Heart Rate (beats/mm) Whit (No. e 71) Blac (No. = k 61)

Slowest 102 110

Mean 105 113

15

subjects,

on

the

second

day

of testing,

the

first

two

measures

were

within

± 5%

(

± 26 msec) of

the

value

for

the

first

session;

the

average

heart

period for the first non-REM period var-ied ± 7%.

BLOOD PRESSURE MEASUREMENT AND RELIABILITY

Brachial systolic blood pressure was measured

from the newborn’s right arm with a Roche Arteriosonde (utilizing a 4 X 10-cm inflatable cuff) whose validity has been established.58 Each

of two

observers

independently

took

three

mea-surements of systolic blood pressure during

non-REM

sleep, immediately after the period during

which average heart period was measured. For

each observer, measurement of the maximum difference between any two of three readings

was

< 4 mm Hg in 96% of measurements.

Differences

between

the

independent

averages

of

the

two

examiners

were

4 mm

Hg

in 84%

of

measurements.

For each non-REM period, the average of the

six

systolic

blood

pressure

determinations

was

calculated. Average blood pressure did not

change

significantly

in

successive

non-REM

periods. The lowest average blood pressure for

the

non-REM

periods

in

a

session

correlated

i:

=

.96

with

the

average

blood

pressure

for

the

first

non-REM

period

and

= .95 with the mean

of

all

the

average

blood

pressures.

The

lowest

average

blood

pressure

in a session

was

the

most

reliable

of the

three

blood

pressure

measures.

For

1 1 of 15 subjects tested on two days, the lowest

average

blood

pressure

of the

non-REM

periods

on the

second

day

was

within ± 4 mm Hg

(

± 6%)

of

the

first

session’s

value;

the

average

blood

pressure

for

the

first

non-REM

period

was

within

±

7

mm

Hg

(

± 10%): and the mean of the

average

blood

pressures

was

within

± 5 mm Hg

(±

7%).

HEART RATE RESULTS

For presenting the heart rate results, the average heart period was converted into heart

rate

in beats

per

minute.

Heart

rate

levels

during

non-REM

sleep

in

this

study

were

somewhat

lower than those observed in other

investiga-tions,24

presumably

because

of

the

effect

of

swaddling.”

Both the slowest heart rate and mean heart rate

were significantly faster

(P

< .001) for black

subjects

than

for

white

subjects

(Table

I).

Fre-quency

distributions

of the

slowest

heart

rates

are

presented in Figure 1, where slowest heart rate levels 110.4 beats per minute were found in

25%

of

white

subjects

and

in

57%

of

black

subjects.

The

mean

of the

slowest

heart

rates

for

white subjects, 105 beats per minute, is identical with the mean heart rate for 15 newborns (pre-sumed to be white) “asleep and motionless” calculated from Figure 2 of another report.’’ In

our

prior study,’ mean heart rate during

non-REM

sleep averaged 108 beats per minute in 35 white subjects and 116 beats per minute in 34 black subjects. In both studies, the difference in heart rate between black subjects and white

subjects

averaged

8 beats

per

minute.

The difference in heart rate between black

subjects

and

white

subjects

does

not

seem

attrib-utable to differences in labor and delivery, although a greater proportion of black women had complications of labor and delivery

(P

< .007), and black women had longer

dura-tions

of

labor

(P

< .003). The heart rate differ-ence remained significant among those with no

complications

of labor

and

delivery

(P

< .004), 52 white subjects and 35 black subjects. Duration of labor

did

not

correlate

with

the

slowest

heart

rate

and,

when two subgroups of subjects were matched for average duration of labor (51 white

subjects,

8.1 hours;

50 black

subjects,

7.8 hours),

the heart rate difference remained significant

(P

< .001). Four black subjects with Apgar scores

of

3 to

6,

indicating

some

cardiorespiratory

distress

at birth,

had

slowest

heart

rates

indistin-guishable from other black newborns.

BLOOD PRESSURE RESULTS

Lowest systolic blood pressure did not differ

significantly

in

74 white

newborns

(average,

74

mm Hg) in comparison to 67 black newborns

(

average, 77

mm

Hg).

These

blood

pressure

mea-surements

are

consistent

with

those

of

other

studies

since

levels

for

sleeping

newborns

have

been reported to be approximately 10 mm Hg lower than for awake newborns’ ‘ I 2

and

blood

pressure

in waking

newborns

on

the

third

post-natal

day

has

been

reported

to average

82 and

84 mm

Hg.”” A recent study reports that in 144

newborns, from 2 to 4 days of age, average

at Viet Nam:AAP Sponsored on September 8, 2020

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(3)

41

,. 117.6 125.9

HEART RATE (BEATS PER MIN.)

tolic

blood

pressure

during

non-REM

sleep

was

73 mm

Lowest

systolic

blood

pressure

did

not

correlate

with

slowest

heart

rate.

Lowest

systolic

blood

pressure

did

correlate

with

the

first

measurement

of

the

mother’s

systolic

blood

pressure

during

pregnancy, r = .23 (No. =

131,

P

< .01)

(evi-dence

of familial

association

of blood

pressure

at

birth);

total

number

of

feedings

from

birth,

i:

=

.32

(No.

=

121,

P

<

.01);

and

total

fluid

and

total

sodium

intake

from

birth,

r

=

.25

(No. =

121,

P

<

.01).

PERINATAL CHARACTERISTICS

There were no significant differences between

the

white

mothers

and

the

black

mothers

in age,

marital

status,

education,

history

of hypertension

in the

mother

or in the

maternal

family,

prepreg-nancy

weight,

relative

weight,

weight

change

during

pregnancy,

blood

pressure

during

preg-nancy,

number

of prenatal

clinic

visits,

gravidity,

parity,

proportion

who

had

complications

of

pregnancy, intake of coffee, aspirin, or alcohol,

use

of cigarettes,

questionnaire

report

of

nervous-ness

or depression,

or proportion

rated

as having

received

a high

level

of

medication

for

deliv-ry#{176}

Gestational

age,

birthweight,

and

height

were

almost

identical

for

the

two

groups

of

subjects

(e.g.,

average birthweights were 3,288 gm and

3,248

gm).

There

were

no

significant

differences

in

sex

ratio,

relative

weight,

ponderal

index,

Quetelet

index,

the

time

from

the

last

medication

for

delivery

to the

time

of test,

the

postnatal

age

in hours,

Apgar

scores

at one

minute

after

birth,

the

total

number

of feedings

from

birth,

the

total

fluid

and

the

total

sodium

intake

from

birth,

the

intake volume per feeding, the newborn’s weight

change

from

the

preceding

day,

the

ounces

of

formula ingested prior to the test session, the

amount

of crying

during

the

session,

or the

rectal

temperature

at

the

end

of

the

session

(average,

36.8 C

for

white

subjects

and

36.9 C

for

black

subjects).

DISCUSSION

Among this low socioeconomic class, urban

population

in

the

northeastern

United

States,

a

racial

difference

in

newborn

heart

rate,

though

#{176}Motherswere rated high in level of delivery medication for any of the following: (1) >50 mg of meperidine; (2) >50 mg

of hydroxyzine; (3) 20 mg of diazepam; (4) intravenous

barbiturate or tranquilizer; or (5) paracervical block.

FIG. 1. Distribution of slowest heart rate for non-REM sleep

periods

for

black subjects and for white subjects.

not

large

(average

8 beats

per

minute),

has

been

replicated. The racial difference in newborn heart rate

has

also

been

replicated

in another

northeast-em

urban

center.

A total

of 257

full-term,

normal

newborns were studied, ranging in age from 48 to 96 hours; 55% were black. On the basis of the mean of three measurements of pulse rate for each newborn, the black newborns had pulse rates that were, on the average, 8 beats per minute faster than the white newborns

(P

< .002).’

The finding of a racial heart rate difference at birth is of intrinsic interest in relation to our understanding of cardiovascular development.

Since

elevated

heart

rate

in young

adults

has

been

shown to be associated with an increased

proba-bility

of

developing

hypertensive

disease,’’

it

has

been speculated that the elevated heart rate in black newborns might be associated with the greater prevalence of hypertensive disease among black adults in this country.

(4)

286

HEART

RATE

IN NEWBORNS

heart

rate

difference

at

birth

is

a

function

of

genetic or of environmental factors. Although

heart

rate

did

not

correlate

with

any

of

the

measured perinatal variables, other factors such as maternal diet or the care and handling of the newborns might have influenced heart rate.

In this study, no significant racial difference in

systolic blood pressure during non-REM sleep was

noted in newborns. A recent investigation of 257

newborns

in

several

differenet

behavioral

states

also

found

no

racial

differences

either

in systolic

or

in

diastolic

blood

pressure.’5

At

older

ages,

comparisons of blood pressure in black children and in white children have yielded conflicting results.”21 By late adolescence, some, but not all, groups of blacks had significantly higher blood pressures.2’4 Thus, racial differences in blood

pressure

have

not

been

found

consistently

at any

age from

birth

through

adolescence.

Systolic blood pressure in the newborn is related both to the total number of feedings from

birth

(which

accounts

for

10%

of the

variance

in

blood

pressure)

and

to

the

total

fluid

intake.

These

variables,

therefore,

should

be

considered

in subsequent

studies

of

newborn

blood

pres-sure.

SUMMARY

Sixty-one

full-term,

appropriate-weight

black

newborns

had

higher

heart

rates,

replicating

a

racial

heart

rate

difference,

but

did

not

differ

significantly

in

systolic

blood

pressure

from

71 white

newborns.

Systolic

blood

pressure

in

the

newborn

is related

both

to

the

total

number

of

feedings

from

birth

and

to the

total

fluid

intake.

J

OSEPH SCHACHTER, M.D., PH.D.

JOHN M. LACHIN III, Sc.D.

J

OYCE L. KERR, PH.D.

FiiNcIs C. WIMBERLY III, M.S.

J

OHN

J.

RATEY

Pittsburgh

Child

Guidance

Center,

and

Department

of Psychiatry,

University

of Pittsburgh

School

of Medicine

Pittsburgh, Pennsylvania

Supported by Research Grant HL-17436 from the

National Heart and Lung Institute and by a grant from the Maurice Falk Medical Fund.

ADDRESS FOR REPRINTS: Pittsburgh Child

Guid-ance Center, 201 Dc Soto Street, Pittsburgh, Pennsylvania 15213.

REFERENCES

1. Schachter

J,

Kerr JL, Wimberly FC, Lachin JM: Heart rate levels of Black and White newborns. Psy-chosom Med 36:513, 1974.

2. Prechtl HFR: Polygraphic studies of the full-term newborn: II. Computer analysis of recorded data. In, MacKeith R, Bax M (eds): Studies in Infancy: Clinic in Developmental Medicine No. 27. London, Heinemann Medical Books Ltd, 1968, p 22. 3. Hutt SJ, Lenard HG, Prechtl HFR: Psychophysiological

studies in newborn infants. In, Lipsitt LP, Reese

HW (eds): Advances in Child Development and

Behavior. London, Academic Press, 1969, vol 4, p 127.

4. AshtOIl R, Connolly K: The relation of respiration rate and heart rate to sleep states in the human newborn. Dev Med Child Neurol 13:180, 1971. 5. Massie HL, Ziedonis

J,

Black I: Ultrasonic measurement of infant blood pressure. Med Instr 7:240, 1971. 6. McLaughlin GW, Kirby RR, Kemnierer WT, de Le Mos

RA: Indirect measurement of blood pressure in

infants utilizing Doppler ultrasound.

J

Pediatr

79:300, 1971.

7. Black IF, Kotrapti N, Massie H: Application of Doppler ultrasound to blood pressure measurement in small infants.

J

Pediatr 81:932, 1972.

8. Dweck HS, Reynolds DW, Cassady C: Indirect blood

pressure measurement in newborns. Am

J

Dis Child

127:492, 1974.

9. Lipton EL, Steinschneider A, Richmond JB: Swaddling, a child care practice: Historical, cultural, and

experimental observations. Pediatrics 35:521, 1965.

10. Picton-Warlow CG, Mayer FE: Cardiovascular

responses to postural changes in the neonate. Arch Dis Child 45:354, 1970.

11. Goodman HC, Cumming GR, Raber MB: Photocell

oscillonieter for measuring systolic pressure in neWl)orn. Am

J

Dis Child 103:152, 1962.

12. Moss AJ, Adams FH: Problems of Blood Pressure in Childhood. Springfield, Illinois, Charles C Thomas, 1962, p 67.

13. Contis C, Lind

J:

Study of systolic blood pressure, heart rate, body temperature of normal newborn infants through the first week of life. Acta Paediatr

l46(Suppl):4l, 1963.

14. Bordiuk JM, Keitel H: Non-pathologic and pathologic

alterations in the blood pressure (BP) of the newborn infant (NB). Clin Res 21:406, 1973. 15. Lee Y-H, Rosner B, Gould

J,

Kass EH: Faniilial

aggre-gation of l)lOod pressures in newborn infants and their mothers. Unpublished data.

16. Levy RL, White PD, Stroud WD, Hillman CC:

Tran-sient tachycardia: Prognostic significance alone and

in association with transient hypertension. JAMA

129:585, 1945.

17. Paffenbarger RS, Thorne MC, \Ving AL: Chronic

disease in former college students: VIII.

Character-istics in youth predisposing to hypertension in later

years. Am

J

Epidemiol 88:25, 1968.

18. Thomas CB, Greenstreet RL: Psychobiological charac-teristics ill youth as predictors of five disease states: Suicide, iiental illness, hypertension, coronary

heart disease, and tumor. Johns Hopkins Med

J

132:16, 1973.

19. Comstock G’sV: An epidemiologic study of blood

at Viet Nam:AAP Sponsored on September 8, 2020

www.aappublications.org/news

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sure levels in a biracial community in the southern

United States. Am J Hyg 65:271, 1957.

20. Johnson BC, Remington RD: A sampling study of blood pressure levels in White and Negro residents of Nassau, Bahamas,

J

Chron Dis 13:39, 1961. 21. Beresford SAA, Holland WW: Levels of blood pressure

in children: A family study. Proc R Soc Med

65:1009, 1973.

22. Dube 5K, Kapoor 5, Ratner H, Tunick F: Blood pressure studies in Black children. Clin Res 21:947, 1973. 23. Wiess NS, Hamill VV, Drizd T: Blood Pressure Levels of

Children 6-1 1 Years: Relationship of Age, Sex, Race,

and Socioeconomic Status. Rockville, Maryland,

DHEW Publication No. (HRA) 74-1617, 1973. 24. Stine OC, Hepner R, Greenstreet R: Correlation of

blood pressure with skinfold thickness and protein levels. Am

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Dis Child 129:905, 1975.

25. Diehl HS: Racial differences in blood pressure. Minn

Med 14:726, 1931.

26. Adams JM: Some racial differences in blood pressures and morbidity in a group of White and Colored workmen. Am

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Med Sci 184:342, 1932.

27. Gover M: Physical impairments of members of low-income farm families. Public Health Rep 63: 1083, 1948.

28. Szent-Gyorgyi N: Blood pressure studies among Amer-ican and foreign-born students. Circulation I 4:17, 1956.

29. Comstock GW: An epidemiologic study of blood pres-sure levels in a biracial community in the southern United States. Am

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30. Rose G: A study of blood pressure among Negro school children.

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31. McDonough JR. Garrison GE, Hames CG: Blood pres-sure and hypertensive disease among Negroes and Whites. Ann Int Med 61:208, 1964.

32. Langford HG, Watson RL, Douglas BH: Factors

affecting blood pressure in population groups. Trans Assoc Am Phys 81:135, 1968.

33. Kilcoyne MM, Richter RW, Alsup PA: Adolescent

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ACKNOWLEDGMENT

We thank C. R. Yoiingquist and T. T. Hayashi for

providing facilities at Magee-Womens Hospital, and A. P. Shapiro for help in preparing the manuscript.

Gonococcal

Periappendicitis

and

Salpingitis

in a Prepubertal

Girl

Gonorrhea

is

the

most

frequently

reported

infectious

disease

in the

United

States.

Salpingitis

and

periappendicitis

secondary

to vaginal

gonor-rhea

are

not

unusual

in the

mature

woman,

but

are rare in the prepubertal girl. We are reporting

a case

of vaginal

gonorrhea,

acute

salpingitis,

and

periappendieitis

in a 5-year-old

girl.

CASE REPORT

An acutely ill 5-year-old girl with a two-week history of a thick, nonpnlritic vaginal discharge and an 18-hour history of fever, vomiting, and severe abdominal pain was admitted

for evaluation. There was a negative history of dysuria, constipation, diarrhea, introduction of vaginal foreign body,

coitus, and molestation.

Vital signs on admission were: temperature, 39.7 C orally;

pulse, 120 beats per minute; respiration, 36 breaths per minute; and blood pressure 100/60. Her abdomen was

diffusely tender to direct palpation and percussion. Rectal examination was not accomplished due to uncooperative-ness. Bowel sounds were decreased. The vulva and vagina were inflamed and a thick, punilent discharge was present. She walked with a painful, stooped gait and preferred to lie with her legs flexed.

Laboratory data obtained on admission included: CBC; hematocrit, 36%; WBC, 10,400/cu mm) with 76% polymor-phonuclear leukocytes, 6% bands, 12% lymphocytes, and 6% monocytes. A voided urine specimen showed: specific gray-ity, 1.020; pH, 7; protein, trace; ketones, moderate; glucose,

negative; 20 to 30 WBC/hpf. Gram stain of vaginal

discharge revealed innumerable WBC, few gram-negative

extracellular diplococci, and gram-negative rods. Abdominal X-ray films showed no radiopaqiie foreign body and no abnormal bowel pattern.

Treatment was begun with intravenously administered ampicillin at a dose of 3(X) mug/kg/day. Vaginal examination

under anesthesia was then performed and revealed no

evidence of trauma or foreign body. The vagina, vulva, and cervix were inflamed and purulent material poured forth from the cervix, which was cultured. Because of progression of abdominal symptoms, a laparotom was performed. An acutely inflamed appendix and an erythematous, swollen,

congested right fallopian tube were observed. An appendec-tomy was done and the right fallopian tube aspirated. Pathological diagnosis of the appendix was periappendicitis

and culture of the tube was sterile. Two cervical cultures obtained at surgery grew pure cultures of Neisseria gonococ-ens.

The remainder of the hospital course was that of improve-ment. She received ampicillin intravenously for three days

and orally on the fourth hospital day. She remained afebrile

after the second hospital day. Her VDRL was nonreactive. She was discharged on orally administered ampicillin.

The diagnosis was discussed with the parents. They recalled that three days prior to onset of vaginal discharge their daughter had slept two nights with a 16-year-old female cousin. She was known to be heterosexually active and to have had a vaginal discharge the weekend she cared for their

child.

Post-hospitalization follow-up was uneventful and cul-tures were negative for N. gonorrhea.

DISCUSSION

Gonococcal

disease

in the

pediatric

patient

is

not rare’2 and may be transmitted venereally or

nonvenereally.’

Prepubertal

girls

usually

manifest

(6)

1976;58;283

Pediatrics

Ratey

Joseph Schachter, John M. Lachin III, Joyce L. Kerr, Francis C. Wimberly III and John J.