Blood pressure references for Polish children and adolescents

Reference blood pressure values obtained using the auscultation method for 2-year-old Japanese children: from the Japan Environment and Children's Study

BACKGROUND

Reference blood pressure (BP) values for Japanese children based on a large number of measurements by auscultation have not yet been established.

METHODS

This was a cross-sectional analysis of data from a birth-cohort study. The data from the sub-cohort study conducted for children at the age of 2 years in the Japan Environment and Children's Study from April 2015 to January 2017 were analyzed. BP was measured via auscultation using an aneroid sphygmomanometer. Each participant was measured in triplicate, and the average value of two consecutive measurements with a difference of less than 5 mmHg was recorded. The reference BP values were estimated using the lambda-mu-sigma (LMS) method and compared with those obtained via the polynomial regression model.

RESULTS

Data from 3361 participants were analyzed. Although the difference between the estimated BP values by the LMS and the polynomial regression model was small, the LMS model was more valid based on the results of the fit curve of the observed values and regression models for each model. For 2-year-old children with heights in the 50th percentile, the 50th, 90th, 95th, and 99th percentile reference values of systolic BP (mmHg) for boys were 91, 102, 106, and 112, and that for girls were 90, 101, 103, and 109, respectively, and those of diastolic BP for boys were 52, 62, 65, and 71, and that for girls were 52, 62, 65, and 71, respectively.

CONCLUSION

The reference BP values for 2-year-old Japanese children were determined based on auscultation and were made available.

Association between Fasting and Postprandial Levels of Liver Enzymes with Metabolic Syndrome and Suspected Prediabetes in Prepubertal Children

Elevated liver enzyme activity may be associated with metabolic syndrome (MetS); however, it is not included in the MetS definition for children. Postprandial changes in the levels of biochemistry tests are related to manifestations of metabolic abnormalities. We assessed the association between fasting and postprandial liver enzymes levels with MetS and elevated hemoglobin A1c (HbA1c) in children aged 9-11. The study included 51 girls and 48 boys, all presumably healthy. In all participants' anthropometric indices, fasting glucose, insulin, lipid profile and HbA1c were measured. Enzymes, including alanine aminotransferase (ALT) and gamma-glutamyl transferase (GGT), were assayed in fasting and postprandial states. Individuals were divided into subgroups: with (MetS(+): n = 26); without MetS (MetS(-): n = 73); with HbA1c levels ≤ 5.3% (n = 39); and ≥5.7% (n = 11). Elevated fasting GGT levels were found in 23% of MetS(+) children and rarely in MetS(-) children; increased postprandial GGT was noted in 35% of MetS(+) individuals. Postprandial GGT changes tend to predict MetS (OR = 1.16; p = 0.092). Increased fasting ALT was found rarely in MetS(+) children, but did not occur in MetS(-) children. HbA1c ≥ 5.7% occurred rarely and neither fasting ALT nor GGT were related to elevated HbA1c. However, postprandial change of ALT was a good positive predictor of increased HbA1c (OR = 1.33; p = 0.021). Postprandial GGT performs better as an indicator of metabolic syndrome occurrence, and instead postprandial ALT may predict prediabetes in prepubertal children.

Relationships between Bone Turnover Markers and Factors Associated with Metabolic Syndrome in Prepubertal Girls and Boys

The associations between individual components of metabolic syndrome (MetS) and bone health in children are complex, and data on this topic are sparse and inconsistent. We assessed the relationship between bone turnover markers and markers of the processes underlying MetS (insulin resistance and inflammation) in a group of presumably healthy children aged 9–11 years: 89 (51 girls, 38 boys) presenting without any features of MetS and 26 (10 girls, 16 boys) with central obesity and two features of MetS. Concentrations of glucose, triglycerides (TG), HDL cholesterol (HDL-C), C-reactive protein (CRP), HbA1c, total 25-hydroxyvitamin D (25(OH)D), intact-P1NP (N-terminal propeptide of type I procollagen), CTX-1 (C-terminal telopeptide of type I collagen) were assayed and insulin resistance was assessed (HOMA-IR). BMI centile, waist circumference (WC) and blood pressure were measured. The presence of MetS in girls resulted in significantly lower concentrations of CTX-1 and a trend to lower CTX-1 in boys. The concentrations of bone formation marker i-P1NP were not affected. Among the features associated with MetS, HOMA-IR appeared as the best positive predictor of MetS in girls, whereas CRP was the best positive predictor in boys. A significant influence of HOMA-IR on the decrease in CTX-1 in girls was independent of BMI centile and WC, and the OR of having CTX-1 below the median was 2.8-fold higher/1SD increased in HOMA-IR (p = 0.003). A weak relationship between CTX-1 and CRP was demonstrated in girls (r = −0.233; p = 0.070). Although TG, as a MetS component, was the best significant predictor of MetS in both sexes, there were no correlations between bone markers and TG. We suggest that dyslipidemia is not associated with the levels of bone markers in prepubertal children whereas CRP is weakly related to bone resorption in girls. In prepubertal girls, insulin resistance exerts a dominant negative impact on bone resorption, independent of BMI centile and waist circumference.

The high-intensity interval training introduced in physical education lessons decrease systole in high blood pressure adolescents

Increased resting blood pressure (BP) is a risk factor for many health complications. The prevalence of elevated BP is growing among adolescents. There is a need to investigate effective ways of decreasing excessive blood pressure in this age group. The study aim was to determine the effect of 10-weeks High-Intensive Interval Training (HIIT)—Tabata protocol—introduced in physical education (PE) lessons on resting blood pressure in adolescents. The sample included 52 boys aged 16.23 ± 0.33 years body height176.74 ± 6.07 (m), body weight 65.42 ± 12.51 (kg), BMI 20.89 ± 3.53 (kg/m²) and 89 girls aged 16.12 ± 0.42 years, body height 164.38 ± 6.54 (m), body weight 56.71 ± 10.23 (kg), BMI 20.93 ± 3.08 (kg/m²) from secondary school. Based on resting BP, the fractions of boys and girls with normal BP and high BP were identified and divided into experimental (EG) and control (CG) groups. EG completed a 10-weeks HIIT program (three cycles of Tabata protocol) implemented in one PE lesson during a week. The duration of the effort was 14 min. The intensity was at 75–80% of maximal heart rate. Changes in systolic and diastolic BP after the experiment were examined. The results indicated the improvement in SBP in EG with high BP compared to the rest of the groups (average reduction of 12.77 mmHg; p < 0.0001). The EG normotensive had a statistically significant higher reduction of SBP comparing CG normotensive (average decrease of 1.81 mmHG; p = 0.0089). HIIT effectively decreases BP in adolescents. Implementing HIIT in PE lessons in secondary school is recommended to improve BP parameters.

The Mediation Role of Fatness in Associations between Cardiorespiratory Fitness and Blood Pressure after High-Intensity Interval Training in Adolescents

BACKGROUND

Low cardiorespiratory fitness (CRF), elevated blood pressure (BP), and high fatness are cardiovascular disease risk factors. It remains unknown how fatness affects the influence of CRF on BP. Therefore, the aim was to examine whether the associations between baseline CRF and HIIT-postintervention resting BP were mediated through fatness in adolescents.

MATERIAL AND METHODS

The sample (n = 64) comprised 28 boys 36 girls aged 16 years. The analysed factors were fitness index- reflecting CRF, body fat mass (BFM), fat mass index (FMI), and body mass index (BMI). Bootstrapped mediation procedures were performed. The mediation analysis was conducted concerning the sex moderation effect.

RESULTS

The mediation effect of sex was confirmed; therefore, mediations models were designed separately for boys and girls. The results showed a statistically significant inverse relationship between baseline CRF and post-intervention systolic blood pressure (SBP) in both sexes (boys: B = -0.603, p = 0.010; girls: B = -0.394, p = 0.037). The relations between CRF and SBP revealed the mediation effect of the BFM and the FMI only in boys.

CONCLUSIONS

Fatness mediated associations between CRF and SBP in boys. Therefore, both CRF and fatness are necessary to maintain positive results of the BP revealed in normal SBP ranges after HIIT.

Comparison of China Reference with Different National and International References: The Prevalence of High Blood Pressure in 695,302 Children and Adolescents in a Metropolis of Yangtze River Delta, China

Objectives

This study aimed to compare performances of China reference and different national references on high blood pressure (HBP).

Methods

A cross-sectional study including 695,302 children and adolescents aged 7 to 17 years in Suzhou, China, was conducted to determine the prevalence of HBP based on U.S., international, Europe, and China references in 2016.

Results

Different percentiles of height and blood pressure were found among four references. Referring to U.S. reference, the prevalence of HBP was the highest with 26.0%, followed by International reference with 20.0%, Europe reference with 19.5%, and China reference with 19.2%. McNemar tests indicated statistically significant differences between HBP prevalence comparing China reference with the other 3 references (P < 0.001). The area under the curve was 0.947, 0.851, and 0.949 for U.S., international, and Europe reference, respectively. U.S. reference showed the highest sensitivity (98.2%), but the lowest specificity (91.2%), and Europe reference showed the highest kappa value (0.893).

Conclusions

The prevalence of HBP varied among these four references, and the appropriate choice of reference would be important to recognize high-risk children and judge the trends of HBP prevalence in the targeted population.

Establishing percentiles for blood pressure based on absolute height for children and adolescents

Background

Evaluating blood pressure (BP) is one element for diagnosing and preventing disease in student populations. The objectives of this research were to (a) identify the range of height for measuring BP adjusted for student populations and (b) propose percentiles for evaluating BP based on height.

Methods

A cross-sectional study was carried out with 3,013 students. Weight, height, and diastolic (DBP) and systolic (SBP) blood pressure were evaluated. Body Mass Index (BMI) was calculated. Height ranges of 5 and 10 cm were generated.

Results

R² values for height ranges of 5 cm consisted of [normotensive: DBP (R² = 10 to 13%) and SBP (R² = 14 to 20%), and for hypertensive: DBP (R² = 0.07 to 15%) and for SBP (R² = 29 to 32%)]. For height ranges of 10 cm, values included: [normotensive: DBP (R² = 10 to 15%), and SBP (R² = 15 to 21%) and for hypertensive: DBP (R² = 0.07 to 16%) and SBP (R² = 29 to 35%)]. For 5 cm height ranges, diferences occurred between both sexes for DBP (in 5 height ranges from 123 to 148 cm and 158 to 168 cm) and for the SBP (in 6 height ranges from 128 to 148 cm and from 158 to 168 cm). In the 10 cm categories, diferences appeared in DBP (from 138 to 148 cm) and in the SBP (from 158 to 168 cm).

Conclusions

Height is a determinant for evaluating blood pressure, and height ranges of 10 cm are more suitable for children and adolescents. The proposed percentiles based on height ranges allowed assessment of the DBP and SBP suggest their use in epidemiological and educational contexts.

A comparison of clinical paediatric guidelines for hypotension with population-based lower centiles: a systematic review

Background

Different definitions exist for hypotension in children. In this study, we aim to identify evidence-based reference values for low blood pressure and to compare these with existing definitions for systolic hypotension.

Methods

We searched online databases until February 2019 (including MEDLINE, EMBASE, Web of Science) using a comprehensive search strategy to identify studies that defined age-related centiles (first to fifth centile) for non-invasive systolic blood pressure in healthy children < 18 years. Existing cut-offs for hypotension were identified in international guidelines and textbooks. The age-related centiles and clinical cut-offs were compared and visualized using step charts.

Results

Fourteen studies with population-based centiles were selected, of which 2 addressed children < 1 year. Values for the fifth centile differed 8 to 17 mmHg for age. We identified 13 clinical cut-offs of which only 5 reported accurate references. Age-related cut-offs for hypotension showed large variability (ranging from 15 to 30 mmHg). The clinical cut-offs varied in agreement with the low centiles. The definition from Paediatric Advanced Life Support agreed well for children < 12 years but was below the fifth centiles for children > 12 years. For children > 12 years, the definition of Parshuram’s early warning score agreed well, but the Advanced Paediatric Life Support definition was above the fifth centiles.

Conclusions

The different clinical guidelines for low blood pressure show large variability and low to moderate agreement with population-based lower centiles. For children < 12 years, the Paediatric Advanced Life Support definition fits best but it underestimates hypotension in older children. For children > 12 years, the Advanced Paediatric Life Support overestimates hypotension but Parshuram’s cut-off for hypotension in the early warning score agrees well. Future studies should focus on developing reference values for hypotension for acutely ill children.

Impact of the 2017 American Academy of Pediatrics Guideline on Hypertension Prevalence Compared With the Fourth Report in an International Cohort

In 2017, the American Academy of Pediatrics (AAP) updated the clinical practice guideline for high blood pressure (BP) in the pediatric population. In this study, we compared the difference in prevalence of elevated and hypertensive BP values defined by the 2017 AAP guideline and the 2004 Fourth Report and estimated the cardiovascular risk associated with the reclassification of BP status defined by the AAP guideline. A total of 47 200 children and adolescents aged 6 to 17 years from 6 countries (China, India, Iran, Korea, Poland, and Tunisia) were included in this study. Elevated BP and hypertension were defined according to 2 guidelines. In addition, 1606 children from China, Iran, and Korea who were reclassified upward by the AAP guideline compared with the Fourth Report and for whom laboratory data were available were 1:1 matched with children from the same countries who were normotensive by both guidelines. Compared with the Fourth Report, the prevalence of elevated BP defined by the AAP guideline was lower (14.9% versus 8.6%), whereas the prevalence of stages 1 and 2 hypertension was higher (stage 1, 6.6% versus 14.5%; stage 2, 0.4% versus 1.7%). Additionally, comparison of laboratory data in the case-control study showed that children who were reclassified upward were more likely to have adverse lipid profiles and high fasting blood glucose compared with normotensive children. In conclusion, the prevalence of elevated BP and hypertension varied significantly between both guidelines. Applying the new AAP guideline could identify more children with hypertension who are at increased cardiovascular risk.

Body mass index percentiles and elevated blood pressure among children and adolescents

It is well established that obesity is associated with an increased risk of elevated and high blood pressure (BP) in children and adolescents. However, it is uncertain whether there is an increase in the risk of elevated and high BP associated with an increase of body mass index (BMI) among children and adolescents whose BMI is in the accepted normal range. Data were available for 58 899 children and adolescents aged 6-17 years from seven national cross-sectional surveys in China, India, Iran, Korea, Poland, Tunisia, and the United States. The subjects were divided into eight percentile subgroups according to their BMI levels based on the World Health Organization recommendations. Elevated BP and high BP were defined using the 2016 international child BP criteria. Compared with the reference subgroup of the 5th-24th percentiles, the odds ratios (ORs) for high BP were 1.27 (95% confidence interval [CI], 1.14-1.41; P < 0.001) in the 25th-49th percentile subgroup, 1.55 (95% CI, 1.39-1.73; P < 0.001) in the 50th-74th percentile subgroup, and 2.17 (95% CI, 1.92-2.46; P < 0.001) in the 75th-84th percentile subgroup, respectively, after adjustment for sex, age, race/ethnicity, height and country. Additionally, the corresponding ORs for elevated BP were 1.21 (95% CI, 1.10-1.32; P < 0.001), 1.55 (95% CI, 1.42-1.69; P < 0.001), and 1.80 (95% CI, 1.62-2.01; P < 0.001), respectively. In conclusion, a BMI in the 25th-84th percentiles, within the accepted normal weight range, was associated with an increased risk of elevated and high BP among children and adolescents. It is important for children and adolescents to keep a BMI at a low level in order to prevent and control hypertension.

Revealing burden of elevated blood pressure among Polish adolescent participants in a population-based ADOPOLNOR study: prevalence and potent risk factors

New category for elevated blood pressure introduced and described by JNC-7 for adults and adopted by the 2004 Working Group for children and adolescents stands for a pre-sign to hypertension. The ongoing rise in prevalence of high blood pressure in children and adolescents demands their regular screening. The objective of this study was to determine prevalence of elevated BP in Polish adolescents and explain the role of sex, age and body weight status as potent risk factors for this condition. A population-based cross-sectional survey was carried out on a sample of 4,941 students (2,451 boys and 2,490 girls) aged 10–18, participants in the ADOPOLNOR study. Body height and weight were measured and BMI was calculated. Blood pressure was measured twice on each visit on the right arm using a fully calibrated TECH MED TM-Z mercury gauge sphygmomanometer with sets of exchangeable cuffs and a clinical stethoscope. The blood pressure classification was determined using the surveillance method. The depended outcome variable was the elevated BP compared to normal BP for systolic (SBP), diastolic (DBP) and combined SBP and/or DBP. Explanatory variables included demographic characteristics, sex and age, and weight status. Two-way ANCOVA, Chi-square Pearson correlation, and multivariate logistic regression analysis (MLRA) were performed using the STATISTICA 13.1 data analysis software system; p-value <0.05 was considered statistically significant (StatSoft Inc. Tulsa, OK, USA). A clear gender pattern was found in prevalence of elevated BP with girls being more likely than boys to have elevated BP (4.9%, 5.3% and 7.4% for SBP, DBP and combined SBP and/or DBP in girls vs 3.5%, 3.5% and 5.9% in boys). The proportion of both genders with elevated BP gradually increased with age with 4.8% (SBP), 2.8% (DBP) and 5.8% (SBP and/or DBP), and 5.1%, 6.4% and 8.4% in early and late adolescence, respectively. Fifteen percent of obese adolescents had elevated SBP, 14.3% elevated DBP and 17.8% had elevated either SBP and/or DBP combined. At multivariate approach, the adjusted odds ratio for predictors of elevated BP revealed sex, age and weight status for SBP and SBP and/or DPB combined. Age and weight status were predictive for elevated DBP. Weight status (BMI) showed the highest predictive potential of elevated BP for both genders. The likelihood of developing elevated BP increased at least twice with each BMI category increase. Thus, overweight and obese adolescents were twice (overweight) and 4 to 5 times (obese) more likely than their normal weight counterparts in developing elevated BP. The study results confirmed predictive potential of sex, age, and weight status in developing elevated BP in adolescents. The highest odds of the weight status indicate that it is the strongest confounder of elevated BP condition.

Height-specific blood pressure cutoffs for screening elevated and high blood pressure in children and adolescents: an International Study

Pediatric blood pressure (BP) reference tables are generally based on sex, age, and height and tend to be cumbersome to use in routine clinical practice. In this study, we aimed to develop a new, height-specific simple BP table according to the international child BP reference table based on sex, age and height and to evaluate its performance using international data. We validated the simple table in a derivation cohort that included 58,899 children and adolescents aged 6-17 years from surveys in 7 countries (China, India, Iran, Korea, Poland, Tunisia, and the United States) and in a validation cohort that included 70,072 participants from three other surveys (China, Poland and Seychelles). The BP cutoff values for the simple table were calculated for eight height categories for both the 90th ("elevated BP") and 95th ("high BP") percentiles of BP. The simple table had a high performance to predict high BP compared to the reference table, with high values (boys/girls) of area under the curve (0.94/0.91), sensitivity (88.5%/82.9%), specificity (99.3%/99.7%), positive predictive values (93.9%/97.3%), and negative predictive values (98.5%/97.8%) in the pooled data from 10 studies. The simple table performed similarly well for predicting elevated BP. A simple table based on height only predicts elevated BP and high BP in children and adolescents nearly as well as the international table based on sex, age, and height. This has important implications for simplifying the detection of pediatric high BP in clinical practice.

Blood Pressure and Its Association with Gender, Body Mass Index, Smoking, and Family History among University Students

Hypertension is one of the major risk factors associated with cardiovascular diseases. In this study, we will assess the frequency of hypertension among healthy university students and its association with gender, body mass index, smoking, and family history of both hypertension and cardiovascular diseases. We screened healthy university students ranging from 18 to 26 years of age. For each participant, we performed blood pressure measurements using a previously validated device and obtained demographic data, body mass index (BMI), smoking status, and family history of both hypertension and cardiovascular diseases. Out of the total number of 505 participants included in this study, 35.2% have blood pressure between 130/80 and 139/89, and 13.5% have blood pressure of more than 140/90. We found significant gender differences in both systolic pressure (p = 0.003) with mean difference = 18.08 mmHg (CI: 16.13 to 19.9) and diastolic pressure (p = 0.011) with mean difference = 3.6 mmHg (CI: 2.06 to 5.14), higher in males than in females. Upon comparing the mean difference in both systolic and diastolic blood pressure with BMI, we found significant differences in both systolic (p < 0.001) and diastolic (p = 0.002) blood pressure. We also found that smokers have significantly (p = 0.025) higher systolic blood pressure (mean difference = 4.2 mmHg, CI: 3.2 mmHg to 8.8 mmHg), but no significant difference for diastolic blood pressure (p = 0.386), compared to nonsmokers. First-degree family history of both hypertension and cardiovascular diseases affected systolic but not diastolic blood pressure. Taking into account the adverse short- and long-term effect of hypertension, we recommend adopting an awareness program highlighting the importance of screening blood pressure in young adolescent populations, keeping in mind that both high BMI and smoking are important modifiable factors.

Preschool children blood pressure percentiles by age and height

We aimed to construct blood pressure (BP) references for the Polish preschool children and to compare them with the United States, German and European references. BP was measured oscillometrically using a validated device in 4378 randomly selected Polish children aged 3-6 years who were free of chronic diseases and behaved quietly during BP measurement. Height and weight were also measured. Gender-specific BP percentiles were constructed for age and height simultaneously with the use of quantile regression and a polynomial regression model. Systolic blood pressure (SBP), diastolic blood pressure (DBP) and mean arterial blood pressure reference percentiles by gender, age and height are presented. The Polish preschool children's 90th and 95th SBP and DBP percentiles were mostly lower than those in the United States, German and IDEFICS study BP references. Compared with the German oscillometric BP reference and with the United States sphygmomanometric BP reference, differences in the 95th SBP percentiles ranged by age from -5 to 0 mm Hg and from -2 to -1 mm Hg, in boys and girls, respectively, whereas the differences in the 95th percentiles of DBP ranged from -7 to -1 mm Hg and from -5 to -1 mm Hg, in boys and girls, respectively. Polish preschool children's BP percentiles based on measurements with the use of a validated oscillometric device in a nationally representative sample are lower than those from the current United States, German and European references. When interpreting BP measurements in children, adequate referential values should be used.

Performance of Eleven Simplified Methods for the Identification of Elevated Blood Pressure in Children and Adolescents

The identification of elevated blood pressure (BP) in children and adolescents relies on complex percentile tables. The present study compares the performance of 11 simplified methods for assessing elevated or high BP in children and adolescents using individual-level data from 7 countries. Data on BP were available for a total of 58 899 children and adolescents aged 6 to 17 years from 7 national surveys in China, India, Iran, Korea, Poland, Tunisia, and the United States. Performance of the simplified methods for screening elevated or high BP was assessed with receiver operating characteristic curve (area under the curve), sensitivity, specificity, positive predictive value, and negative predictive value. When pooling individual data from the 7 countries, all 11 simplified methods performed well in screening high BP, with high area under the curve values (0.84-0.98), high sensitivity (0.69-1.00), high specificity (0.87-1.00), and high negative predictive values (≥0.98). However, positive predictive value was low for most simplified methods, but reached ≈0.90 for each of the 3 methods, including sex- and age-specific BP references (at the 95th percentile of height), the formula for BP references (at the 95th percentile of height), and the simplified method relying on a child's absolute height. These findings were found independently of sex, age, and geographical location. Similar results were found for simplified methods for screening elevated BP. In conclusion, all 11 simplified methods performed well for identifying high or elevated BP in children and adolescents, but 3 methods performed best and may be most useful for screening purposes.

Establishing International Blood Pressure References Among Nonoverweight Children and Adolescents Aged 6 to 17 Years

BACKGROUND

Several distributions of country-specific blood pressure (BP) percentiles by sex, age, and height for children and adolescents have been established worldwide. However, there are no globally unified BP references for defining elevated BP in children and adolescents, which limits international comparisons of the prevalence of pediatric elevated BP. We aimed to establish international BP references for children and adolescents by using 7 nationally representative data sets (China, India, Iran, Korea, Poland, Tunisia, and the United States).

METHODS AND RESULTS

Data on BP for 52 636 nonoverweight children and adolescents aged 6 to 19 years were obtained from 7 large nationally representative cross-sectional surveys in China, India, Iran, Korea, Poland, Tunisia, and the United States. BP values were obtained with certified mercury sphygmomanometers in all 7 countries by using standard procedures for BP measurement. Smoothed BP percentiles (50th, 90th, 95th, and 99th) by age and height were estimated by using the Generalized Additive Model for Location Scale and Shape model. BP values were similar between males and females until the age of 13 years and were higher in males than females thereafter. In comparison with the BP levels of the 90th and 95th percentiles of the US Fourth Report at median height, systolic BP of the corresponding percentiles of these international references was lower, whereas diastolic BP was similar.

CONCLUSIONS

These international BP references will be a useful tool for international comparison of the prevalence of elevated BP in children and adolescents and may help to identify hypertensive youths in diverse populations.

Who is at higher risk of hypertension? Socioeconomic status differences in blood pressure among Polish adolescents: a population-based ADOPOLNOR study

In Poland, there is no data on parental socioeconomic status (SES) as a potent risk factor in adolescent elevated blood pressure, although social differences in somatic growth and maturation of children and adolescents have been recorded since the 1980s. This study aimed to evaluate the association between parental SES and blood pressure levels of their adolescent offspring. A cross-sectional survey was carried out between 2009 and 2010 on a sample of 4941 students (2451 boys and 2490 girls) aged 10-18, participants in the ADOPOLNOR study. The depended outcome variable was the level of blood pressure (optimal, pre- and hypertension) and explanatory variables included place of residence and indicators of parental SES: family size, parental educational attainments and occupation status, income adequacy and family wealth. The final selected model of the multiple multinomial logistic regression analysis (MLRA) with backward elimination procedure revealed the multifactorial dependency of blood pressure levels on maternal educational attainment, paternal occupation and income adequacy interrelated to urbanization category of the place of residence after controlling for family history of hypertension, an adolescent's sex, age and weight status. Consistent rural-to-urban and socioeconomic gradients were found in prevalence of elevated blood pressure, which increased with continuous lines from large cities through small- to medium-sized cities to villages and from high-SES to low-SES familial environments. The adjusted likelihood of developing systolic and diastolic hypertension decreased with each step increase in maternal educational attainment and increased urbanization category. The likelihood of developing prehypertension decreased with increased urbanization category, maternal education, paternal employment status and income adequacy. Weight status appeared to be the strongest confounder of adolescent blood pressure level and, at the same time, a mediator between their blood pressure and parental SES.

CONCLUSION

The findings of the present study confirmed socioeconomic disparities in blood pressure levels among adolescents. This calls for regularly performed blood pressure assessment and monitoring in the adolescent population. It is recommended to focus on obesity prevention and socioeconomic health inequalities by further trying to improve living and working conditions in adverse rural environments.

Blood pressure percentiles in 22,051 German children and adolescents: The PEP Family Heart Study

BACKGROUND

Strong associations between blood pressure (BP) and overweight raise the question whether overweight children (body mass index (BMI) ≥85th percentile) should be included in the normative database.

METHODS

Using the LMS (Lamda-Mu-Sigma) method, we developed age-, gender-, and height-adjusted percentile curves for systolic blood pressure (SBP) and diastolic blood pressure (DBP) at the 50th, 85th, 90th, 95th, and 97th percentiles in 22,051 German youths (18,917 normal-weight, 1,938 overweight, and 1,196 obese) aged 3-18 years from yearly cross-sectional surveys of the PEP Family Heart Study Nuremberg.

RESULTS

Among children, we found no gender differences for BP and BMI. Male adolescents are taller and heavier. The mean prevalence of hypertension and obesity is 7.3% and 5.2% among children and 7.2% and 5.8% among adolescents, respectively. The prevalence of elevated BP increased substantially by weight groups achieving 24.4% in obese females and 21.9% in obese males with odds ratios of 5.9 (95% confidence interval (CI): 5.1-7.5) and 4.3 (95% CI: 3.5-5.2), respectively. The shapes of the 10 LMS-smoothed SBP and DBP percentile curves differ substantially between gender and weight group. The normal-weight percentiles are nearly identical with the overall growth charts, but separate percentiles for overweight and obese youths provide considerably higher values, such as 148/91 vs. 136/86 mm Hg for a 17-year-old male and 136/91 vs. 123/81 mm Hg for female, respectively, at the 90th percentile.

CONCLUSIONS

Because of substantially higher BP percentiles, separate databases for overweight and obese children and adolescents are strongly recommended.

Percentile distribution of blood pressure readings in relation to body mass index: a populationbased cross-sectional study ADOPOLNOR

Recent upward trends toward elevated blood pressure and increased weight expressed in terms of body mass index in children and adolescents call for regular monitoring of their physical growth and age-related changes in blood pressure. This requires adequate tools - reference values of a normal blood pressure range. The main objective of this study was to provide sex- and BMI-specific percentile reference values for systolic and diastolic blood pressure based on the adolescent Polish population, participants in the ADOPOLNOR study. A cross-sectional survey was carried out on a representative, randomly selected cohort of 4,941; 2,451 male and 2,490 female students aged 10-18 years, residents in Wielkopolska province and its capital, the city of Poznań. All examinations were performed in school nursery rooms during morning hours according to standard procedures. Body height and weight were measured and BMI was calculated. Blood pressure was measured twice on each occasion on the right arm using a fully calibrated TECH MED TM-Z mercury gauge sphygmomanometer with sets of exchangeable cuffs and a clinical stethoscope. The blood pressure classification was determined using the surveillance method. For each participant, the mean of measurements taken on each of the three occasions was calculated and served as his/her final blood pressure value. Using the LMS method, fitted percentile curves were created for BMI-related systolic and diastolic blood pressure. The findings revealed that age related blood pressure pattern was similar in boys and girls. It showed a steady increase of systolic and diastolic blood pressure with age. There was a positive correlation between the systolic and diastolic blood pressure indicating that when systolic blood pressure increased so diastolic did (r=0.61 at p<0.01). Boys were likely to have relatively higher mean values of systolic and diastolic blood pressure and steeper slope for BMI-related change in blood pressure than girls. Similar pattern was found for age-related changes in BMI. The quotation of 3rd, 5th, 10th, 15th, 25th, 50th, 75th, 85th, 90th, 95th, and 97th at any given BMI between 12 kg/m2 and 35 kg/m2 provided indication of the entire variation in blood pressure of adolescent males and females aged 10-18 years. The sex- and BMI-specific reference values and charts for systolic and diastolic blood pressure may be a useful tool in monitoring blood pressure for early detection of its abnormal level and treatment of children and adolescents with high blood pressure.

Guidelines on guidelines: focus on isolated systolic hypertension in youth

Current guidelines on isolated systolic hypertension (ISH) suggest the same treatment to patients of all ages. Application of these guidelines in youth with ISH may not be appropriate, as presently no data show adverse outcome or benefit of drug therapy in this group. Simple noninvasive tonometric techniques now enable physicians to measure the central aortic pressure waveform and amplification of the pressure pulse. ISH in youth is usually caused by high amplification of the central pressure wave, whereas ISH in the elderly (>age 60) is attributable to aortic stiffening. This is the only group with ISH shown to have an adverse prognosis and to warrant drug therapy.

Oscillometric blood pressure percentiles for Polish normal-weight school-aged children and adolescents

OBJECTIVE

The objective of this study was to construct blood pressure (BP) references with the use of a validated oscillometric device for normal-weight, school-aged children and adolescents and to study BP predictors.

METHODS

BP was measured in 14 266 randomly selected, normal-weight Polish children and adolescents aged 7-18 years, who were free of chronic disease, using a validated oscillometric device (Datascope Accutor Plus). Height, weight and waist circumference were measured. BP percentiles were constructed for age and height simultaneously with the use of a polynomial regression model. The normative values of BP were compared with the US normal-weight reference, German oscillometric reference, and Polish auscultatory reference.

RESULTS

Reference BP percentiles by sex, age and height are presented. At median height, the age-specific differences in the 90th BP percentiles compared with German oscillometric reference ranged in the case of boys from -3 to 2  mmHg and from -5 to -1  mmHg, SBP and DBP, respectively, and in the case of girls from 0 to 3  mmHg and from -5 to -1  mmHg, SBP and DBP, respectively. As compared to weight, waist circumference was stronger SBP predictor in low birth weight boys.

CONCLUSION

The study provides BP references for oscillmetric device, based on a current, nationally representative sample of normal-weight Polish children and adolescents. The normative values of BP were compared taking into consideration the height and BMI differences, the pubertal spurt, the methods of BP measurement and percentile construction.

Main characteristics and participation rate of European adolescents included in the HELENA study

Background

Participation rate and response rate are key issues in a cross sectional large-scale epidemiological study. The objective of this paper is to describe the study population and to evaluate participation and response rate as well as the key nutritional status variables in male and female adolescents involved in the HELENA study.

Methods

A multi-stage random cluster sampling with a target sample of 3000 adolescents aged [12.5 to 17.5] years, stratified for geographical location and age, was carried out. Information for participants and non-participants (NP) was compared, and participation and response rates to specific questionnaires were discussed.

Results

3,865 adolescents aged [12.5 to 17.5] years (1,845 females) participated in the HELENA study, of whom 1,076 (568 females) participated in the blood sampling. 3,528 (1,845 females) adolescents were finally kept for statistical analysis. Participation rates for the schools and classes differed importantly between countries. The participation rate of pupils within the participating classes also differed importantly between countries. Sex ratio, mean age and BMI were similar between NP and participating adolescents within each centre, and in the overall sample. For all the questionnaires included in the database, the response rate of questionnaires was high (more than 80% of questions were completed).

Conclusion

From this study it could be concluded that participation rate differed importantly between countries, though no bias could be identified when comparing the key study variables between participants and non-participants. Response rate for questionnaires was very high. Future studies investigating lifestyle and health in adolescents can optimize their methods when considering the opportunities and barriers observed in the HELENA study.

European guidelines on managing adverse effects of medication for ADHD

The safety of ADHD medications is not fully known. Concerns have arisen about both a lack of contemporary-standard information about medications first licensed several decades ago, and signals of possible harm arising from more recently developed medications. These relate to both relatively minor adverse effects and extremely serious issues such as sudden cardiac death and suicidality. A guidelines group of the European Network for Hyperkinetic Disorders (EUNETHYDIS) has therefore reviewed the literature, recruited renowned clinical subspecialists and consulted as a group to examine these concerns. Some of the effects examined appeared to be minimal in impact or difficult to distinguish from risk to untreated populations. However, several areas require further study to allow a more precise understanding of these risks.

Different diagnostic criteria significantly affect the rates of hypertension in 18-year-old high school students

INTRODUCTION

Childhood hypertension is defined based on the normative distribution of blood pressure (BP), but from the age of 18 years high BP is diagnosed using adult criteria. We compared the rates of diagnosis of hypertension in a group of 18-year-old subjects using BP percentiles and the adult criteria.

MATERIAL AND METHODS

Blood pressure was measured by registered nurses in 1472 18-year-old high-school students (780 men and 692 women). Also weight, height and waist circumference were recorded.

RESULTS

The prevalence of hypertension was 9% (16.2% in men and 0.9% in women, p < 0.001) using adult cut-off values and 14.7% (21.9% in men and 6.6% in women, p < 0.001) using percentile charts. Obesity was diagnosed in 2.4% and overweight in 13% of subjects, respectively. The relative risk ratio of diagnosing hypertension according to the adult criteria in overweight or obese subjects was 2.94 (95% CI 2.25-3.86) in men and 6.44 (95% CI 3.51-11.82) in women.

CONCLUSIONS

Our study indicates high prevalence of hypertension in 18-year-old students - especially in men - and the importance of obesity as a risk factor of hypertension. The use of percentile charts instead of adult cut-off values increases the prevalence of hypertension in men by 35% from 16.2% to 21.9% and in women more than 7 times, i.e. from 0.9% to 6.6%. It seems reasonable to use higher (i.e. 98(th)) percentile values for definition of high blood pressure.