Home blood pressure monitoring in children: how many measurements are needed?

Performance of Home-Based and Ambulatory Blood Pressure Monitoring in Obese Children and Their Correlation With End Organ Damage

BACKGROUND

The increasing prevalence of childhood obesity has led to a corresponding increase in hypertension among children, necessitating early identification of subclinical target organ damage for accurate cardiovascular risk assessment. However, in the pediatric population, there is a paucity of literature comparing ambulatory and home blood pressure monitoring, and this knowledge gap is exacerbated by limited access to ambulatory blood pressure monitoring (ABPM) facilities, particularly in developing countries, where pediatricians often resort to home blood BP monitoring as the preferred option.

METHODS

In this cross-sectional study with 60 obese children (aged 5-18 years) at tertiary health care in central India, we aimed to comprehensively characterize blood pressure profiles, including office, ambulatory, and home, and investigated their correlations with indicators of end-organ damage.

RESULTS

Among 60 children, 26 (43.3%) participants were found to be hypertensive based on 24-hour-ABPM evaluation. Masked hypertension (MH) and white coat hypertension (WCH) were observed in 21.6% and 13.3%, respectively. Surprisingly, 20% of participants were identified as hypertensive through 7-day home BP monitoring (HBPM). A notable discordance of 36.6% was between HBPM and ABPM results. Moreover, 26.7% of the children had end-organ damage, with higher odds associated with night-time systolic ambulatory hypertension in the adjusted regression model (OR = 1.06, 95% CI: 1.03-1.10, P < 0.001).

CONCLUSIONS

The study highlights 24-hour ABPM's vital role in classifying hypertensive status, especially in high-risk children. The diagnostic performance of HBPM shows poor sensitivity in detecting MH and lower specificity in identifying WCH compared to ABPM. This limitation translates to missed opportunities for early preventive interventions.

Reliability of systolic blood pressure measured by parents in young children at home using a hand held doppler device and aneroid sphygmomanometer

OBJECTIVE

We report data regarding systolic BP monitoring in children aged <5 years performed over a 2-week period by parents at home using a hand-held doppler device and aneroid sphygmomanometer for SBP measurements (HDBPM). Our objectives were to compare health professional measured office systolic BP by doppler device (Office-SBP Doppler ) with parent measured home systolic BP using the same doppler device (Home-SBP Doppler ). We also report data evaluating reliability and optimal number of days of measurement required.

DESIGN AND METHODS

We taught parents to measure systolic BP and assessed their technique using a hand-held doppler device and aneroid sphygmomanometer. We requested parents to perform three consecutive BP measurements twice daily (ideally morning and evening around similar times) when the child was awake, settled and cooperative.

RESULTS

Over a 3-year period, data from 48 of 62 children who underwent HDBPM measurements were evaluated with median (IQR) age of 1.9 (0.9, 3.6) years, 27 (56%) boys and 14 (29%) on antihypertensive medication. Office-SBP Doppler was 2.9 ± 8.9 mmHg [95% confidence interval (CI), -14.4 to 20.4, P  = 0.026] higher than Home-SBP Doppler . Mean Home-SBP Doppler between Week-1 and Week-2 monitoring was similar -0.45 ± 3.5 mmHg (95% CI, -7.35 to 6.45, P  = 0.41). Morning HDBPM measurements were lower than evening with a mean difference of -2.77 ± 3.92 mmHg, P  < 0.001). Over Week-1, mean Home-SBP Doppler was closer to mean Office-SBP Doppler with increasing cumulative days of monitoring and with smaller standard deviations suggesting that readings become more reliable from day 4 onwards.

CONCLUSIONS

HDBPM is a reliable method for measuring systolic BP in young children with BP levels measured by parents comparable to those performed by health professional in clinic. HDBPM technique described here and performed by parents over a 7-day period with a minimum of 4-days, offers a reliable and reproducible technique to measure blood pressure at home.

Home blood pressure monitoring: methodology, clinical relevance and practical application: a 2021 position paper by the Working Group on Blood Pressure Monitoring and Cardiovascular Variability of the European Society of Hypertension

The present paper provides an update of previous recommendations on Home Blood Pressure Monitoring from the European Society of Hypertension (ESH) Working Group on Blood Pressure Monitoring and Cardiovascular Variability sequentially published in years 2000, 2008 and 2010. This update has taken into account new evidence in this field, including a recent statement by the American Heart association, as well as technological developments, which have occurred over the past 20 years. The present document has been developed by the same ESH Working Group with inputs from an international team of experts, and has been endorsed by the ESH.

Reproducibility of Office and Out-of-Office Blood Pressure Measurements in Children: Implications for Clinical Practice and Research

This study aimed to evaluate the reproducibility of office (OBP), ambulatory (ABP), and home blood pressure (HBP) measurements in children and adolescents, and their implications in diagnosing hypertension in clinical practice and in pediatric hypertension research. Apparently healthy children and adolescents referred for suspected hypertension were included. Measurements of 2-visit OBP, 7-day HBP, and 24-hour ABP were performed twice, 1 to 6 months apart. Reproducibility was quantified using the SD of differences between repeated measurements. The sample size of clinical trials comparing the efficacy of antihypertensive drugs using each method was calculated. Fifty-eight individuals were analyzed (mean age, 13.0±2.9 years, 60.3% boys). The reproducibility of 24-hour ABP (SD of differences 5.7/4.5 systolic/diastolic) and HBP (5.9/5.0 mm Hg) were comparable and superior to that of visit-2 OBP (9.2/7.8) and awake (6.7/5.5) or asleep ABP (7.6/6.1). As a consequence, a parallel-group comparative trial aiming to detect a difference in the effect of 2 drugs of 10 mm Hg systolic BP, would require 36 participants when using OBP measurements, 14 using 24-hour ABP, and 15 using HBP (102/34/42 respectively for detecting a 5 mm Hg difference in diastolic BP). For a crossover design trial, the corresponding sample sizes are 9/3/4 for systolic BP and 26/9/11 for diastolic, respectively. These data suggest that in children and adolescents 24-hour ABP and 7-day HBP have similar reproducibility, superior to OBP and daytime or asleep ABP. These findings have major implications in diagnosing hypertension in children in clinical practice and in designing clinical research trials in pediatric hypertension.

Home Blood Pressure Monitoring in Children and Adolescents: Systematic Review of Evidence on Clinical Utility

PURPOSE OF REVIEW

For the accurate diagnosis and management of hypertension, out-of-office blood pressure evaluation using ambulatory (ABPM) or home monitoring (HBPM) is currently recommended. In children, there is considerable evidence on the clinical utility of ABPM, whereas the evidence on HBPM is limited. This systematic review presents (i) the benefits of HBPM in children; (ii) the evidence on normal range, diagnostic accuracy, and relationship with preclinical organ damage; and (iii) guidance for devices, monitoring schedule, and interpretation.

RECENT FINDINGS

HBPM is a useful adjunct to the conventional office measurements for the evaluation of children with suspected or treated hypertension. HBPM is feasible in children and has good reproducibility, diagnostic accuracy and acceptability by users, and relatively low cost. Thus, it has greater potential for widespread and long-term use than ABPM, which is more expensive and often not available or not tolerated. Automated monitors that have been clinically validated specifically in children should be used with appropriate cuff size. HBPM for 7 days (minimum 3) with duplicate morning and evening measurements (minimum 12 readings) should be performed in children with suspected or treated hypertension before each office visit. Until more data become available, in case of diagnostic disagreement between office blood pressure and HBPM, treatment decisions should be based on ABPM. HBPM is clinically useful in children with hypertension. More research is needed on its clinical application, and more automated devices need to be clinically validated in this population.

Home blood pressure monitoring in pediatric hypertension: the US perspective and a plan for action

The 2017 US guidelines for pediatric hypertension place considerable emphasis on blood pressure measurements, which are the cornerstone for hypertension diagnosis and management. It is recognized that when the diagnosis of hypertension is based solely on office blood pressure measurements, many children are misclassified (over- or underdiagnosed). Therefore, out-of-office blood pressure evaluations using ambulatory or home blood pressure monitoring are often necessary to obtain an accurate diagnosis. Strong evidence for the diagnostic and clinical value of ambulatory blood pressure monitoring in children has justified its central role in decision making in recent pediatric recommendations. However, ambulatory blood pressure monitoring is not widely accessible in primary care. There is little evidence for home blood pressure monitoring in children, yet this method is widely available and feasible for the evaluation of elevated blood pressure in children. This article presents a case for using home blood pressure monitoring for the management of children with suspected or treated hypertension in clinical practice in comparison to using office measurements or ambulatory blood pressure monitoring, as well as its optimal application. More research on home blood pressure monitoring in children is urgently needed.

2016 European Society of Hypertension guidelines for the management of high blood pressure in children and adolescents

Increasing prevalence of hypertension (HTN) in children and adolescents has become a significant public health issue driving a considerable amount of research. Aspects discussed in this document include advances in the definition of HTN in 16 year or older, clinical significance of isolated systolic HTN in youth, the importance of out of office and central blood pressure measurement, new risk factors for HTN, methods to assess vascular phenotypes, clustering of cardiovascular risk factors and treatment strategies among others. The recommendations of the present document synthesize a considerable amount of scientific data and clinical experience and represent the best clinical wisdom upon which physicians, nurses and families should base their decisions. In addition, as they call attention to the burden of HTN in children and adolescents, and its contribution to the current epidemic of cardiovascular disease, these guidelines should encourage public policy makers to develop a global effort to improve identification and treatment of high blood pressure among children and adolescents.

Office blood pressure measurements with oscillometric devices in adolescents: a comparison with home blood pressure

PURPOSE

Compare multiple in office BP measurements in adolescents using an oscillometric device with out-of-office blood pressure measurements (home blood pressure monitoring - HBPM).

MATERIALS AND METHODS

Office measurements were performed with validated semi-automatic devices twice (3 minutes interval) in two different moments (1 week apart), with a total of four readings. These BP readings were named R1, R2, R3 and R4 (following the sequence they were performed), FDM (mean of two readings on first day) and SDM (mean of two readings on second day) and SRM (R2-R4 means). The HBPM protocol included two day-time and two evening-time measurements over 6 days.

RESULTS

A total of 1024 students between 12 and 17 years were included (mean age 14.68 years; 52.4% females). The mean systolic blood pressure (SBP) values of R2, SDM and SRM were similar to HBPM values. Regarding diastolic blood pressure (DBP) HBPM value was different than R4. High SBP and DBP correlation coefficients with HBPM values were found for R2, SDM and SRM values.

CONCLUSION

The second office BP measurement performed with an oscilometric device in adolescents was comparable to HBPM values, suggesting that two office readings might be suitable to rule out hypertension in this age group.

A systems-based approach to managing blood pressure in children following kidney transplantation

Hypertension is one of the most common and well-known complications following kidney transplantation in children. Yet, despite numerous available therapies many pediatric kidney transplant recipients continue to have poorly controlled blood pressure, suggesting that traditional approaches to blood pressure management in this population might be inadequate. Over the last two decades, the Chronic Care Model has been developed to improve chronic illness outcomes through delivery system design and clinical information systems that support patient self-management and provider decision-making. In this educational review we discuss key elements of managing blood pressure following pediatric kidney transplantation and suggest ways that they may be reliably implemented into clinical practice using principles from the Chronic Care Model.

Ambulatory and home blood pressure monitoring in children and adolescents: diagnosis of hypertension and assessment of target-organ damage

The prevalence of elevated blood pressure in children and adolescents is more common than previously believed and often represents the early onset of essential hypertension, particularly in adolescents. The definition of hypertension in children is based on distribution criteria and normalcy tables that provide blood pressure percentiles for each measurement method (office, ambulatory and home) according to the individual's age, gender and body size. Owing to the white coat and masked hypertension phenomena, ambulatory blood pressure monitoring is indispensable for the diagnosis of hypertension in children. Home blood pressure monitoring in children has been less well studied, and at present, treatment decisions should not be based solely on such measurements. Hypertension-induced preclinical target-organ damage (mainly echocardiographic left ventricular hypertrophy) is not uncommon in children and should be evaluated in all hypertensive children. Other indices of target-organ damage, such as carotid intima-media thickness, pulse wave velocity and microalbuminuria, remain under investigation in pediatric hypertension.

Home blood pressure in children and adolescents: a comparison with office and ambulatory blood pressure measurements

AIM

To compare BP measurements of children and adolescents using different methods office BP (OBP), ambulatory BP monitoring (ABPM) and home BP measurement (HBPM) and to study their correlations.

METHOD

Individuals were evaluated between 5 and 15 years of age who had been referred because of a previous high BP. OBP was measured with the OMRON-705CP. Three measurements were carried out at 5-min intervals. HBPM were taken using the same device, two measurements at 5-min intervals in the morning and in the evening during 7 days. ABPM was performed using the SpaceLabs 90207 monitors.

RESULTS

A total of 109 children and adolescents were evaluated (9.82 ± 2.63 years), 52.3% boys, 56.9% non-white. The office systolic BP (SBP) was lower than in daytime ABPM (p < 0.001) but similar HBPM (p = 0.294), and the office diastolic BP (DBP) was lower than daytime ABPM (p < 0.001) and in HBPM (p = 0.035). The SBP and DBP at HBPM was lower than daytime ABPM (p < 0.001). Daytime ambulatory BP was more closely associated with home readings (SBP r = 0.731 and DBP r = 0.616) than with office's readings (SBP r = 0.653 and DBP r = 0.394).

CONCLUSION

The BP of children and adolescents varies depending on the place and manner of measurement. ABPM presents better correlation with HBPM than with the office measurements.

Office, ambulatory and home blood pressure measurement in children and adolescents

There is an increasing interest in pediatric hypertension, the prevalence of which is rising in parallel with the obesity epidemic. Traditionally the assessment of hypertension in children has relied on office blood pressure (BP) measurements by the physician. However, as in adults, office BP might be misleading in children mainly due to the white coat and masked hypertension phenomena. Thus, out-of-office BP assessment, using ambulatory or home monitoring, has gained ground for the accurate diagnosis of hypertension and decision-making. Ambulatory monitoring is regarded as indispensable for the evaluation of pediatric hypertension. Preliminary data support the usefulness of home monitoring, yet more evidence is needed. Office, ambulatory and home BP normalcy tables providing thresholds for diagnosis have been published and should be used for the assessment of elevated BP in children.

Prevalence and predictors of masked hypertension detected by home blood pressure monitoring in children and adolescents: the Arsakeion School study

BACKGROUND

Studies using ambulatory blood pressure (BP) monitoring have shown that in children and adolescents masked hypertension (MH) is not uncommon. This school-based study investigated the prevalence and the characteristics of MH diagnosed using home BP measurements.

METHODS

A total of 765 subjects aged 6-18 years were assessed with office (two visits, six readings) and home BP measurements (3 days, 12 readings). Office hypertension was diagnosed using the US Task Force normalcy tables and home hypertension using the Arsakeion normalcy tables (> or = 95th percentile for both). White-coat hypertension (WCH) was defined as office hypertension but low home BP (<95th percentile) and MH as home hypertension but low office BP (<95th percentile).

RESULTS

On the basis of office BP measurements of the first visit 3.3% of participants had MH, 5.9% WCH, and 2.7% hypertension compared to 4.2, 2.1, and 1.8%, respectively, when a two-visit-average BP was used (P < 0.001 vs. first visit). Subjects with MH or WCH did not differ from hypertensives or normotensives regarding age, gender, or height. However, weight, body mass index (BMI), waist and hip circumference, and office and home BP values fell in between those of normotensives and hypertensives. Prehypertension (office BP: 90-95th centile) and increased BMI were independent predictors of MH.

CONCLUSIONS

In children and adolescents MH detected by home BP monitoring is not uncommon and is associated with prehypertension and overweight. Repeated office measurements are essential for the precise diagnosis. MH and WCH in children appear to be intermediate phenotypes of hypertension.