Blood pressure measurement in children and

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SPECIAL ARTICLE

Blood pressure measurement in children and

adolescents: key element in the evaluation of arterial hypertension

La medida de la presión arterial en ni˜ nos y

adolescentes: elemento clave en la evaluación de la hipertensión arterial ^夽

Julio Álvarez

, Francisco Aguilar

, Empar Lurbe

aDepartamentodePediatría,ConsorcioHospitalGeneral,UniversidaddeValencia,Spain

bCIBERFisiopatologíaObesidadyNutrición(CB06/03),InstitutodeSaludCarlosIII,Spain

Received10March2022;accepted26April2022 Availableonline1June2022

KEYWORDS Bloodpressure;

Hypertension;

Children;

Adolescents;

HyperChildNET

Abstract Arterialhypertensionisthemainmodifiableriskfactorforcardiovasculardisease, occupyingthefirstplaceamongthecausesoflossoflifeyearsadjustedfordisability.Inrecent years,arterialhypertensioninchildrenandadolescentshasgainedgroundincardiovascular medicinethankstoprogressmadeinseveralareas,fundamentallyinpathophysiologicaland clinicalresearch.Despitetheadvancesthathavebeenmadeinrecentyears,theprevention, diagnosisandtreatmentofhighbloodpressureinchildrenandadolescentsstillhaveroomfor improvement.Inthissense,thecorrectmeasurementofbloodpressureisespeciallyimportant, sinceitincludesaseriesofessentialelementssuchasthemeasurementdevices,theregulated procedureandtheinterpretationoftheresultsbasedonpercentilesaccordingtoage,gender andheight.Theavailabilityofafreeaccesscalculatorfacilitatesthediagnosisandmonitoring ofarterialhypertensionhttps://hyperchildnet.eu/.

©2022Publishedby Elsevier Espa˜na, S.L.U.onbehalf ofAsociaci´onEspa˜nolade Pediatr´ıa.

ThisisanopenaccessarticleundertheCCBY-NC-NDlicense(http://creativecommons.org/

licenses/by-nc-nd/4.0/).

夽 Pleasecitethisarticleas:ÁlvarezJ,AguilarFandLurbeE,Lamedidadelapresiónarterialenni˜nosyadolescentes:elementoclaveen laevaluacióndelahipertensiónarterial,AnalesdePediatría.2022;96:536.

∗Correspondingauthor.

E-mailaddress:[email protected](E.Lurbe).

2341-2879/©2022PublishedbyElsevierEspa˜na,S.L.U.onbehalfofAsociaci´onEspa˜noladePediatr´ıa.Thisisanopenaccessarticleunder theCCBY-NC-NDlicense(http://creativecommons.org/licenses/by-nc-nd/4.0/).

PALABRASCLAVE Presiónarterial;

Hipertensión;

Ni˜nos;

Adolescentes;

HyperChildNET

Resumen Lahipertensiónarterialeselprincipalfactorderiesgomodificableparalaenfer- medad cardiovascularocupandoelprimerlugarentrelascausasdepérdidadea˜nosdevida ajustadospordiscapacidad.Enlosúltimosa˜noslahipertensiónarterialenni˜nosyadolescentes haganadoterrenoenlamedicinacardiovasculargraciasalosavancesendiversasáreasdela investigación fundamentalmentefisiopatológicayclínica.Apesardelosavancesquesehan llevadoacaboenlosúltimosa˜nos,laprevención,diagnósticoytratamientodelahipertensión arterialenni˜nosy adolescentestodavíasonsusceptibles demejorar. Enestesentidocobra especialrelevancialamedidacorrectadelapresiónarterialquecontemplaunaseriedeele- mentos indispensablescomo sonlosdispositivos demedición, elprocedimientoregladoyla interpretacióndelosresultadosenbaseapercentilessegúnedad,sexoytalla.Ladisponibili- daddeunacalculadoradeaccesolibrefacilitaeldiagnósticoyseguimientodelahipertensión arterialhttps://hyperchildnet.eu/.

©2022PublicadoporElsevierEspa˜na,S.L.U.ennombredeAsociaci´onEspa˜noladePediatr´ıa.

Esteesunart´ıculoOpenAccessbajolalicenciaCCBY-NC-ND(http://creativecommons.org/

licenses/by-nc-nd/4.0/).

Introduction

Arterialhypertension(HTN)isthemainmodifiableriskfac- torforcardiovasculardisease,whichistheleadingcauseof lossofdisability-adjustedlife-years.¹ Inrecentyears,HTN inchildren andadolescentshasgainedground inthefield ofcardiovascularmedicineduetoadvancesinseveralareas ofresearch,chieflypathophysiologicalandclinical.Therec- ommendationofHTNguidelinesforchildrenandadolescents ofmeasuringarterialbloodpressure(BP)fromage3years^2---4 and longitudinal studies have evinced thatmild elevation of BP early in life is muchmore common than previously believedandthatHTNinadultshasitsrootsinadolescence andchildhood.^5---7Beforeage3years,BPshouldbemeasured inthepresenceoffactorsthatincreasetheriskofHTN,such aspretermbirth,lowbirthweight,neonataldiseaserequir- ingintensivecare,congenitalheartdisease,renaldisease, treatmentwithdrugsthatraiseBP,oncologicalorhaemato- logicaldisease,solidorganorbonemarrowtransplantation orincreasedintracranialpressure.²

Althoughnumerousstudieshaveassessedtheprevalence ofHTNinchildrenandadolescents,itisdifficulttodeter- minedue to mainly3 reasons: (i)There arephysiological changes in BP associated with growth and development, which means that thereare nofixed thresholds todefine elevationof systolicor diastolicBP. This complicationhas ledtotheapplicationofpercentilesforage,sexandheight, definingHTNasaBPvalueat the95thpercentile(P95)or higher.(ii)VariationinthedefinitionofHTNusedbythe3 mostrecentclinicalguidelines,publishedinEurope,²United States³ andCanada.⁴(iii)Consideringthevariabilityof BP frombeattobeat,itwasnecessarytorequirethatthesys- tolicand/ordiastolicBPbepersistentlyaboveestablished thresholdson3separateoccasionsfordiagnosisofHTN.Asa result,manycross-sectionalstudieswithasinglemeasure- mentofBPcouldnotdeterminetheprevalenceofHTN.

Arecentlypublishedmeta-analysisthatincludeddatafor 185000childrenandadolescentsaged19yearsoryounger foundanoverallprevalenceofHTNof4%.⁸Thisprevalence varieswithinthepaediatricagegroup,withHTNdetected in 4.3% of children at age 6 years and 7.9% at 14 years,

subsequently dropping to 3.3% at 19 years.In agreement withotherstudies,theprevalenceofHTNwashigherinthe presenceofobesity(15%),comparedtooverweight(5%)and normalweight(1.9%).Thereviewalsonoteda75%increase intheprevalenceofHTNfrom2000to2015,whichcanbe explainedinpartbytheincreaseinobesityinthepaediatric population.

Atpresent,itiswellknownthatinchildrenandadoles- cents,theprevalence ofsecondaryHTNisof1%,andthat primaryHTNisthe mostfrequent typeofHTN inthisage group, especially in adolescents.⁹ Primary HTN is usually asymptomaticor,insomecases,maycausemildsymptoms suchasheadache,epistaxisorchangesinbehaviourandaca- demicperformance,andthereforetheassociationbetween HTNandthesesymptomsmayoftenbeoverlooked,whichis whyitisimportanttostartmeasuringBPatage3years,as recommendedbyeveryguideline.^2---4DetectingabnormalBP valuesintheearlystagesoflifecanallowimplementationof correctivemeasurestoreducetheburdenofcardiovascular disease.

Despite the advances made in recent years, the diag- nosisandtreatmentofHTNcanstillbeimproved.Correct measurementofBPisparticularlyimportantinthisregard.

Methodology for blood pressure measurement

Bloodpressuremeasurementisconsideredoneofthemost importantassessmentsinclinicalpractice,but,asProfessor ThomasG.Pickeringalreadywrotein2005,‘‘Bloodpressure determinationcontinuestobeoneofthemost important measurementsinallofclinicalmedicineandisstilloneof themostinaccuratelyperformed.’’¹⁰ Thereareaseriesof indispensableelementsthatneedtobetakenintoaccount forthecorrectmeasurementofBP.

DevicesforBPmeasurement

TheEuropeanSociety ofHypertension(ESH)guidelinesfor the management of high blood pressure in children and adolescents), the American Academy of Pediatrics (AAP) formanagementofhighBPand,recently,theHypertension

Canadaguidelines,dictatethattheauscultatorytechnique is themethodofchoice fordiagnosis ofHTN.^2---4However, duetorestrictionstotheuseofmercurysphygmomanome- tersandadvancesinoscillometricdevices,theoscillometric methodsiscurrentlymostwidelyusedformeasurementof BP.

Toestablishthecorrectmethodologyfortheuseofthese devices,in2021 theESH publishedpracticeguidelinesfor officeandout-of-officebloodpressuremeasurement.¹¹This guideline contemplates theuse of automated BP measur- ing devices for clinical practice as long as the monitors used have been validated in children and adolescents.

There are websites that provide updated lists on the devices that are appropriate for each population. With theseconcernsinmind,theESHandtheInternationalSoci- ety of Hypertension have developed the initiative known as STRIDE BP (www.stridebp.org). A list of devices val- idated in the paediatric population is also available at www.dableducational.org.Devicesthattaketriplicateread- ingsautomaticallyarepreferred.Itisworthnotingthatnone oftheautomateddevicesformeasurementofBPatthewrist havebeenvalidatedinthisagegroup.

Ifnoneofthevalidateddevicesareavailable,itispossi- bletouseamanual(hybrid)electronicauscultatorydevice with an LCD or LED mercury column-like display or an aneroidsphygmomanometer.Thelatterrequirecalibration at leastoncea year.Once thecuff isinflated, itmust be deflatedatarateof2---3mmHg/s,usingKorotkoffsound1 fordeterminationofsystolicBP(SBP)andKorotkoffsound 5 for the diastolic blood pressure (DBP). For the latter, Korotkoffsound4shouldbeusedifsoundsarestillpresent atfullcuffdeflationorbelowthe40mmHgpoint.

Bloodpressuremeasurementprocedure

BasedontherecommendationsoftheESH,¹⁰ thefollowing stepsarerequiredtocorrectlyobtainBPmeasurements:

Verify thatthe child/adolescenthasnotconsumed any stimulantsubstances(cocoa/cola),smokedorexercised in the30minpriortothemeasurementofBP.

Select the appropriate cuff based on the mid-upper armcircumference,measuredatthemidpointbetweenthe elbowandshoulder.

Placethecuffonthearmabovetheantecubitalfossaand sitthepatientonachairinaquietenvironmentatapleasant temperature,withminimuminteractionwithstaff,withthe backstraightandsupported,thefeetflatonthefloorand thearmrestingonatable

After3−5min ofrest,make aninitial BPmeasurement andthenmake2moremeasurements,with1-minuteinter- vals between readings. The ambulatory BP value will be calculatedasthemeanofthelast2measurements.

Armselection

Inthefirstvisit,theBPshouldbemeasuredinbotharms.A differencegreaterthan10mmHgshouldbeconfirmedwith repeatedmeasurements.Ifthedifferenceisconfirmed,the measurementsofBPwillbemadeinthearmwiththehigh- est values.In thecase of adifference inBP greater than 20mmHg,amorethoroughinvestigationisrequiredtorule outvascularstenosis.

Table1 Mainsourcesoferrorinbloodpressuremeasure- mentinchildrenandadolescents.

Sourceoferror Problem

Patient Nervousorcrying(infant) Recentconsumptionofstimulant substances(cocoa,cola...) Notlongenoughrestingperiod beforeBPmeasurement Equipment UseofdevicethathasNOTbeen

validated

UseofdevicethathasNOTbeen calibrated

Wrongcuffsize

Cuffnotrecommendedbydevice manufacturer

Cuffortubinginpoorcondition Technique Inadequatepositioningofpatient

Incorrectcuffplacement (position/tightness) Incorrectplacementof stethoscope(forauscultation) Takingfewerthan3BP measurements

Cuffselection

Withthepatientintheseatedposition,measurethemid- armcircumference(between shoulderandelbow).Record thecircumferenceandchoosetheappropriatecuff(onein whichtherangeprintedonthecuffitselfincludesthemea- suredcircumference).The most commoncuffsizes inthe paediatricagegroupare:17---22,22−32and32−42cm.Cor- rectselectionofthecuffiscrucial,asasmaller-than-needed cuffwilloverestimateBPvalues,andviceversa.Onlythe cuffsprovidedby themanufacturer forany givenmonitor modelshouldbeusedforBPmeasurement.

Thecuffmustbeplacedwiththearterymarkpositioned intheanteriorsurfaceofthearm(2−3cmabovetheantecu- bitalfossa)withthearmrestingonthetableanditsmidpoint attheleveloftheheart(Fig.1).Thecuffshouldbeequally tightatthetopandbottomedges,anditshouldbepossible tofitafingerunderthecuffatbothedges.

In patients with severe obesity (arm circumference

>42cm),considerusingspecialconicalcuffs, asrectangu- larcuffsmayoverestimateBPvalues.Ifthesecuffsarenot available,a validatedelectronic wrist-cuffdevicemay be used.

Table1summarisesthemostcommonerrorsthatmaybe madeinmeasuringBPinchildrenandadolescents.

InterpretationofBPreadings

Contrarytotheadult population,aspreviouslynoted,the definitionof HTNin children andadolescents inbased on thenormal distribution of BP in healthy children andnot inthecardiovascularmorbidityandmortalityassociatedto specificBPvalues.

In 2016, the ESH published its most recent recommendations,² maintaining the values published

Figure1 Bloodpressuremeasurementprocedure(modifiedfromaposterpublishedbytheEuropeanSocietyofHypertension¹¹).

(ImagesusedafterobtaininglicensefromShutterstock).

in the Fourth Report as reference for the population up to 16 years of age.¹² A year later, the AAP modified the reference values of the Fourth Report,¹² excluding participants withoverweight or obesity.³ The discrepancy between published referencevalues is a subjectthat has attractedconsiderableinterestandsparkeddebate.Astudy conductedbyLurbeetal.¹³ thatcomparedhowpaediatric patients indifferentage groups wouldbeclassified based ontheapplicationofdifferentreferencevaluesfoundthat theuseoftheAPPcriteria³ledtoclassificationofagreater proportion of children as having HTN or high-normal BP compared tothe ESH criteria.² To assess the impact that thesetwostandardshaveinclinicalpractice,studieshave analysed the presence of manifestations characteristic of HTN, such as an increasedleft ventricular mass index,^2,3 in children classified according tothecriteria established in these 2 guidelines. One such study¹⁴ and a recently published meta-analysis¹⁵ concluded that the use of the AAP criteriacompared totheESH criteriaresulted in the identificationofHTNinahigherproportionofpatients,but that this did not result in a more accurate prediction of left ventricular hypertrophy.^14,15 In consequence, the ESH hasmaintainedtheclassificationcriteriaestablishedinthe 2016guidelines.²

To facilitatethedetectionofhighBPvaluesinchildren andadolescents,weattachasimplifiedversionoftherefe- rencevaluetables(Table2).Thistablepresentsthevalues

Table2 TableforscreeningofhighBPvaluesbasedonthe EuropeanSocietyofHypertensionguidelinesforthemana- gementofhighbloodpressureinchildrenandadolescents². Age(years) Bloodpressure(mmHg)

Male Female

SBP DBP SBP DBP

1 94 49 97 52

2 97 54 98 57

3 100 59 100 61

4 102 62 101 64

5 104 65 103 66

6 105 68 104 68

7 106 70 106 69

8 107 71 108 71

9 109 72 110 72

10 111 73 112 73

11 113 74 114 74

12 115 74 116 75

13 117 75 117 76

14 120 75 119 77

15 122 75 120 78

≥16 135 85 135 85

DBP,diastolicbloodpressure;SBP,systolicbloodpressure.

Table3 Definitionandclassificationofhypertensioninchildrenandadolescents.² SBPand/orDBP

<16years ≥16yearsandadults

Normal <P90 <130/85

Normal-high ≥P90y<P95 130−139/85−89

Hypertension

Stage1 ≥P95toP99and5mmHg 140−159/90−99

Stage2 >P99plus5mmHg 160−179/100−109

IsolatedsystolicHTN SBP≥P95andDBP<P90 SBP≥140andDBP<90

DBP,diastolicbloodpressure;HTN,hypertension;P90,90thpercentile;P95,95thpercentile;P99,99thpercentile;SBP,systolicblood pressure.

AdaptedfromtheEuropeanSocietyofHypertensionguidelinesforthemanagementofhighbloodpressureinchildrenandadolescents.²

of the 90th percentile for age for the 5th percentile for height.Ifthesystolicand/ordiastolicBPvalueofthechild understudyisbelowthevaluesforsexandagepresented inthistable,thechildisnormotensiveanddoesnotrequire further assessment other than the BP measurements per- formed aspart of theroutinecare of healthychildren. If theBPvaluesarehigher,thereferencevaluespublishedby theESHshouldbeapplied,inadditiontofollowingtherec- ommendationsfor managementprovidedintheguidelines of thissociety.²Recently, thanks totheworkof theCOST ActionHyperChildNET,fundedbytheEuropeanUnion(refe- renceCA19115),¹⁶thefirstonlinecalculatorhasbeenmade availablethatappliesthereferencevaluesproposedbythe ESHforchildrenandadolescents.²Thistoolcanbeaccessed forfreeathttps://hyperchildnet.eu/.

ThediagnosisofHTNisbasedonBPpercentiledistribu- tionsforage,sexandheightuptoage16years.

From this age, the definition of HTN is based on the criteriaestablishedbytheguidelinesdevelopedcollabora- tivelybytheEuropean Societyof CardiologyandtheESH, or140/90mmHg.¹⁷Table3presentsthepercentilesusedto establish thediagnosisin childrenagedlessthan 16years andtheBPthresholdsusedinadolescentsaged16yearsor older.

Blood pressurevalues in children and adolescentsmay vary from visit to visit. Thus, there is evidence that the prevalenceofelevatedBPvalues(abovetheP95)decreases by53% inthesecond visitandbyupto77.7%inthe third visit compared to the first visit when BP is measured.¹² Therefore,HTNshouldneverbediagnosedbasedonvalues obtainedinasinglevisit,unlessofficeBPvaluesarecompa- tiblewithsymptomaticHTN,stage2HTNinpatientsunder 16years,orabove180/110mmHginpatientsaged16years orolder.ToconfirmthediagnosisofHTNbasedonofficeBP, atleast2or3additionalofficeassessmentsofBPmustbe madeina1-to4-weekperiod(dependingonBPvaluesand theriskofunderlyingdisease).

All guidelines^2---4 recommend confirmation of the HTN diagnosis with24-hambulatory or homeBP monitoringto ruleoutwhite-coatHTN.

Fig.2presentsthehypertensiondiagnosisalgorithmpro- posedby theESH² forfollowup ofpatientsafter officeBP measurement.

Bloodpressuremeasurementinnewbornsand infants

Neonatalhypertensionisuncommon,buthasbeendetected withincreasingfrequency.Blood pressureshouldbe mea- suredintheright arm,andoscillometricBPmeasurement with a device validated in newborns is the most widely usedmethod.The lengthof the cuff bladdershould span 80%---100% of the arm circumference. The published data arelimitedasregardsreferencevalues,andtherisks,treat- mentandlong-termresults.Therearenoclinicalpractice guidelinesandthe managementis based onclinical judg- mentandexpertopinion.Theavailablereferencevaluesare thosepublishedbyetal.in2012,whichincludeBPvaluesin infantsfrom26to44weeksofpostconceptionalage.¹⁸

Inthecaseofinfants,currentrecommendationscontem- platemeasurementintherightarm,acuffwithabladder widthofapproximately50%ofthemid-armcircumference, usingavalidatedoscillometricdeviceandwithperformance of 3 measurements 2min apart.¹⁹ The reference values appliedto infants aged1 month to 1year continue to be thosepublishedin1987.²⁰

Inbothcases,theapproachtodiagnosisissimilartothe oneemployedinolderchildren.

Beyond office blood pressure

Atpresent,therearemethodsavailabletoobtainBPread- ingsoutsidetheoffice.Theyinclude:

a) 24-h ambulatory blood pressure monitoring (ABPM).

AmbulatoryBPmonitorsareportabledevicesthatallow collectionofmorethan80BPreadingsoutsidetheoffice whilethechildoradolescentisengagedinusualevery- day life. The valuesobtained by ABPMhave proven to bemorereproducibleandmorestronglycorrelatedwith target-organdamagecomparedtoofficeBPvalues.²Four differentBPphenotypeshavebeenestablishedbasedon the combination of office BP and ABMP values. When thereisagreementbetweenboth,BPvaluesmaybenor- malwithbothmethods,whichisknownasnormotension, orhigh,whichisknownassustainedHTN.Ifthereisdis- agreement between office andambulatory values,the

Figure2 HypertensiondiagnosisalgorithmbasedontheEuropeanSocietyofHypertensionguidelines.²

possiblephenotypesarewhite-coatHTN(highofficeBP valuesandnormalambulatoryBPvalues)ormaskedHTN (normal office values and high ambulatory values). In consequence,theESHrecommendsperformanceofABPM ineverypatientwithadiagnosisofHTNbasedonoffice BPmeasurement,especiallyifprescriptionofantihyper- tensivemedicationiscontemplated,inordertoprevent initiationofantihypertensivetreatmentinpatientswith white-coatHTN.²Thistechniquemustbecarriedoutin centres experiencedin the diagnosis andtreatment of HTN.ThereferencevaluesforABPMandtheindications foritsusearedetailedintheESHguideline.²

b) HomeBPmonitoring.Thisapproachhasalsoprovenuse- ful,asthereisevidenceofsuperiorreproducibilityand ahighercorrelation withtargetorgandamageinhome BPmonitoringvaluescomparedtoofficeBPvalues.^2---4It requires minimal trainingof the family,explaining the importanceofmaking3consecutiveBPmeasurements, inthemorningaswellasintheevening,atleast3or4 daysinoneweek(although7consecutivedaysisprefer- able),alwayspriortotakinganyantihypertensivedrugs (if applicable).The readings should bemadefollowing the procedure recommended above (Fig. 2) and with monitorsvalidatedinchildrenandadolescents.Theval- ues must be recorded in a form tobe evaluated at a later timeby the paediatricianincharge. To interpret values,themeanofallreadingsiscalculated,excluding valuesrecordedthefirstday,followedbycalculationof thecorrespondingpercentilebasedonthereferenceval- uespublishedintheESHguideline.²HomeBPmonitoring isindicated forfollowupofpatientswithadiagnosis of HTN,whetherornottheyarereceivingantihypertensive medication.

c) OtherBPmeasurementapproaches.Newdevicesforesti- mationofBPvaluesbasedonemergingtechnologiesare

enteringthemarket.TheseincludecufflessBPmeasuring devices,basedon(amongother variables)the calcula- tionof thepulsewavevelocity. Thesedevices,shaped asawristwatch or wristband, couldbeuseful, asthey allowcontinuousmonitoringofBPvalues.However,none ofthemhavebeen properlyvalidatedinthepaediatric population,sotheiruseisnotcurrentlyrecommended.

HyperChildNET calculator

In order to facilitate the interpretation of measured BP values for diagnosis and followup of children and adolescents, HyperChildNET has developed a free-access calculator that allows quick assessment of office BP val- ues. Itsuse facilitatesthe diagnosis and followup of HTN (https://hyperchildnet.eu/).

Funding

This publicationis basedon thework of the COST Action HyperChildNET(CA19115),withthesupportofCOST(Euro- pean Cooperation in Science and Technology) and the Horizon2020FrameworkProgramoftheEuropeanUnion.

Appendix A. Supplementary data

Supplementarymaterialrelatedtothisarticlecanbefound, in the online version, at doi:https://doi.org/10.1016/

j.anpede.2022.04.011.

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