Springer Nature is making SARS-CoV-2 and COVID-19 research free. View research | View latest news | Sign up for updates

Bedside detection of low systemic flow in the very low birth weight infant on day 1 of life


We aimed to assess the relationship between the clinical and biochemical parameters of perfusion and superior vena cava (SVC) flow in a prospective observational cohort study of very low birth weight (VLBW) infants. Newborns with congenital heart disease were excluded. Echocardiographic evaluation of SVC flow was performed in the first 24 h of life. Capillary refill time (forehead, sternum and toe), mean blood pressure, urine output and serum lactate concentration were also measured simultaneously. Thirty-eight VLBW infants were examined. Eight patients (21%) had SVC flow less than 40 ml/kg/min. There was a poor correlation between the capillary refill time (in all sites), mean blood pressure, urine output and SVC flow. The correlation coefficient for the serum lactate concentration was r = −0.28, p = 0.15. The median serum lactate concentration was 3.5 (range 2.8–8.5) vs. 2.7 (range 1.2–6.9) mmol/l (p = 0.01) in low flow versus normal flow states. A serum lactate concentration of >2.8 was 100% sensitive and 60% specific for detecting a low flow state. Combining a capillary refill time of >4 s with a serum lactate concentration of >4 mmol/l had a specificity of 97% for detecting a low SVC flow state. Serum lactate concentrations are higher in low SVC flow states. A capillary refill time of >4 s combined with serum lactate concentrations >4 mmol/l increased the specificity and positive and negative predictive values of detecting a low SVC flow state.

This is a preview of subscription content, log in to check access.

Fig. 1


  1. 1.

    Abubacker M, Yoxall CW, Lamont G (2003) Peri-operative blood lactate concentrations in pre-term babies with necrotising enterocolitis. Eur J Pediatr Surg 13:35–39 doi:10.1055/s-2003-38298

  2. 2.

    Dempsey EM, Barrington KJ (2006) Diagnostic criteria and therapeutic interventions for the hypotensive very low birth weight infant. J Perinatol 26:677–681 doi:10.1038/sj.jp.7211579

  3. 3.

    Dempsey EM, Barrington KJ (2007) Treating hypotension in the preterm infant: when and with what: a critical and systematic review. J Perinatol 27:469–478 doi:10.1038/sj.jp.7211774

  4. 4.

    Deshpande SA, Platt MP (1997) Association between blood lactate and acid-base status and mortality in ventilated babies. Arch Dis Child Fetal Neonatal Ed 76:F15–F20

  5. 5.

    Evans N, Iyer P (1993) Change in blood pressure after treatment of patent ductus arteriosus with indomethacin. Arch Dis Child 68:584–587

  6. 6.

    Evans N, Iyer P (1994) Assessment of ductus arteriosus shunt in preterm infants supported by mechanical ventilation: effect of interatrial shunting. J Pediatr 125:778–785

  7. 7.

    Evans N, Iyer P (1994) Incompetence of the foramen ovale in preterm infants supported by mechanical ventilation. J Pediatr 125:786–792

  8. 8.

    Evans N, Kluckow M (1996) Early determinants of right and left ventricular output in ventilated preterm infants. Arch Dis Child Fetal Neonatal Ed 74:F88–F94

  9. 9.

    Evans N, Osborn D, Kluckow M (2005) Preterm circulatory support is more complex than just blood pressure. Pediatrics 115:1114–1115; author reply 1115–1116

  10. 10.

    Fitzgerald MJ, Goto M, Myers TF, Zeller WP (1992) Early metabolic effects of sepsis in the preterm infant: lactic acidosis and increased glucose requirement. J Pediatr 121:951–955 doi:10.1016/S0022-3476(05)80350-6

  11. 11.

    Groenendaal F, Lindemans C, Uiterwaal CS, de Vries LS (2003) Early arterial lactate and prediction of outcome in preterm neonates admitted to a neonatal intensive care unit. Biol Neonate 83:171–176 doi:10.1159/000068927

  12. 12.

    Hunt RW, Evans N, Rieger I, Kluckow M (2004) Low superior vena cava flow and neurodevelopment at 3 years in very preterm infants. J Pediatr 145:588–592 doi:10.1016/j.jpeds.2004.06.056

  13. 13.

    Izraeli S, Ben-Sira L, Harell D, Naor N, Ballin A, Davidson S (1993) Lactic acid as a predictor for erythrocyte transfusion in healthy preterm infants with anemia of prematurity. J Pediatr 122:629–631 doi:10.1016/S0022-3476(05)83551-6

  14. 14.

    Kluckow M, Evans N (2000) Low superior vena cava flow and intraventricular haemorrhage in preterm infants. Arch Dis Child Fetal Neonatal Ed 82:F188–F194 doi:10.1136/fn.82.3.F188

  15. 15.

    Kluckow M, Evans N (2000) Superior vena cava flow in newborn infants: a novel marker of systemic blood flow. Arch Dis Child Fetal Neonatal Ed 82:F182–F187 doi:10.1136/fn.82.3.F182

  16. 16.

    Kluckow M, Seri I, Evans N (2007) Functional echocardiography: an emerging clinical tool for the neonatologist. J Pediatr 150:125–130 doi:10.1016/j.jpeds.2006.10.056

  17. 17.

    LeFlore JL, Engle WD (2005) Capillary refill time is an unreliable indicator of cardiovascular status in term neonates. Adv Neonatal Care 5:147–154 doi:10.1016/j.adnc.2005.02.008

  18. 18.

    Osborn DA, Evans N, Kluckow M (2003) Hemodynamic and antecedent risk factors of early and late periventricular/intraventricular hemorrhage in premature infants. Pediatrics 112:33–39 doi:10.1542/peds.112.1.33

  19. 19.

    Osborn DA, Evans N, Kluckow M (2004) Clinical detection of low upper body blood flow in very premature infants using blood pressure, capillary refill time, and central-peripheral temperature difference. Arch Dis Child Fetal Neonatal Ed 89:F168–F173 doi:10.1136/adc.2002.023796

  20. 20.

    Osborn DA, Evans N, Kluckow M, Bowen JR, Rieger I (2007) Low superior vena cava flow and effect of inotropes on neurodevelopment to 3 years in preterm infants. Pediatrics 120:372–380 doi:10.1542/peds.2006-3398

  21. 21.

    Raju NV, Maisels MJ, Kring E, Schwarz-Warner L (1999) Capillary refill time in the hands and feet of normal newborn infants. Clin Pediatr (Phila) 38:139–144 doi:10.1177/000992289903800303

  22. 22.

    Seri I, Evans J (2001) Controversies in the diagnosis and management of hypotension in the newborn infant. Curr Opin Pediatr 13:116–123 doi:10.1097/00008480-200104000-00005

  23. 23.

    Strozik KS, Pieper CH, Roller J (1997) Capillary refilling time in newborn babies: normal values. Arch Dis Child Fetal Neonatal Ed 76:F193–F196

  24. 24.

    Wardle SP, Yoxall CW, Weindling AM (1999) Peripheral oxygenation in hypotensive preterm babies. Pediatr Res 45:343–349 doi:10.1203/00006450-199903000-00009

  25. 25.

    Wodey E, Pladys P, Bétrémieux P, Kerebel C, Ecoffey C (1998) Capillary refilling time and hemodynamics in neonates: a Doppler echocardiographic evaluation. Crit Care Med 26:1437–1440 doi:10.1097/00003246-199808000-00034

Download references

Author information

Correspondence to J. Miletin.

Rights and permissions

Reprints and Permissions

About this article

Cite this article

Miletin, J., Pichova, K. & Dempsey, E.M. Bedside detection of low systemic flow in the very low birth weight infant on day 1 of life. Eur J Pediatr 168, 809 (2009). https://doi.org/10.1007/s00431-008-0840-9

Download citation


  • Very low birth weight
  • Low superior vena cava flow
  • Lactate
  • Capillary refill time