Ambulatory blood pressure monitoring in children
- Joseph T Flynn, MD, MS
Joseph T Flynn, MD, MS
- Professor of Pediatrics
- University of Washington
- Section Editors
- David R Fulton, MD
David R Fulton, MD
- Section Editor — Pediatric Cardiology
- Associate Professor of Pediatrics
- Harvard Medical School
- Tej K Mattoo, MD, DCH, FRCP
Tej K Mattoo, MD, DCH, FRCP
- Section Editor — Pediatric Nephrology
- Professor of Pediatrics
- Wayne State University School of Medicine
Ambulatory blood pressure monitoring (ABPM) has become a helpful tool in evaluating blood pressure (BP) in children. It is increasingly used to assess patients with variable BP readings in the office, wide discrepancies between the BP readings at home and in the clinician's office (ie, "white coat" hypertension), and secondary forms of hypertension such as chronic kidney disease (CKD).
The utility and limitations of pediatric ABPM, and information on performing and interpreting ABPM studies in children will be reviewed here. The definition, diagnosis, and treatment of hypertension in children based upon office BP measurement (casual BP) are discussed separately. (See "Definition and diagnosis of hypertension in children and adolescents" and "Ambulatory (outpatient) treatment of hypertension in children and adolescents".)
ABPM can be successfully used in the evaluation of infants, toddlers, and older children [1-7]. However, ABPM needs to be performed in a standardized, reliable fashion to provide accurate recordings, especially in small children and infants .
Device — ABPM uses a portable automated device that records blood pressure (BP) over a specific time period (usually 24 hours). ABPM monitors most commonly used in children are small oscillometric devices, which are worn on a belt in a pouch. Oscillometric ABPM devices directly measure the mean arterial pressure and back-calculate the systolic and diastolic BP using an algorithm that is unique to each device manufacturer. Development of normative data for pediatric ABPM has been difficult because of the variation of each algorithm . Devices utilizing the auscultatory technique are also available, but are less frequently used in children because they are more cumbersome to wear [6,8]. In addition, there are no published normative pediatric ABPM data for auscultatory devices .
Procedural approach — In our center, we follow the approach that is outlined in the 2014 Scientific Statement from the American Heart Association (AHA) on ABPM in children and adolescents, which includes the following key points for obtaining accurate, reliable, and reproducible results in children :
- Flynn JT, Urbina EM. Pediatric ambulatory blood pressure monitoring: indications and interpretations. J Clin Hypertens (Greenwich) 2012; 14:372.
- Lurbe E, Sorof JM, Daniels SR. Clinical and research aspects of ambulatory blood pressure monitoring in children. J Pediatr 2004; 144:7.
- Graves JW, Althaf MM. Utility of ambulatory blood pressure monitoring in children and adolescents. Pediatr Nephrol 2006; 21:1640.
- Urbina E, Alpert B, Flynn J, et al. Ambulatory blood pressure monitoring in children and adolescents: recommendations for standard assessment: a scientific statement from the American Heart Association Atherosclerosis, Hypertension, and Obesity in Youth Committee of the council on cardiovascular disease in the young and the council for high blood pressure research. Hypertension 2008; 52:433.
- Flynn JT. Ambulatory blood pressure monitoring in children: imperfect yet essential. Pediatr Nephrol 2011; 26:2089.
- Flynn JT, Daniels SR, Hayman LL, et al. Update: ambulatory blood pressure monitoring in children and adolescents: a scientific statement from the American Heart Association. Hypertension 2014; 63:1116.
- Varda NM, Gregoric A. Twenty-four-hour ambulatory blood pressure monitoring in infants and toddlers. Pediatr Nephrol 2005; 20:798.
- O'Sullivan JJ, Derrick G, Griggs P, et al. Ambulatory blood pressure in schoolchildren. Arch Dis Child 1999; 80:529.
- Seeman T, Palyzová D, Dusek J, Janda J. Reduced nocturnal blood pressure dip and sustained nighttime hypertension are specific markers of secondary hypertension. J Pediatr 2005; 147:366.
- Macumber IR, Weiss NS, Halbach SM, et al. The Association of Pediatric Obesity With Nocturnal Non-Dipping on 24-Hour Ambulatory Blood Pressure Monitoring. Am J Hypertens 2016; 29:647.
- Wühl E, Witte K, Soergel M, et al. Distribution of 24-h ambulatory blood pressure in children: normalized reference values and role of body dimensions. J Hypertens 2002; 20:1995.
- National High Blood Pressure Education Program Working Group on High Blood Pressure in Children and Adolescents. The fourth report on the diagnosis, evaluation, and treatment of high blood pressure in children and adolescents. Pediatrics 2004; 114:555.
- Salgado CM, Jardim PC, Viana JK, et al. Home blood pressure in children and adolescents: a comparison with office and ambulatory blood pressure measurements. Acta Paediatr 2011; 100:e163.
- Pickering TG, Shimbo D, Haas D. Ambulatory blood-pressure monitoring. N Engl J Med 2006; 354:2368.
- Sorof JM, Portman RJ. Ambulatory blood pressure monitoring in the pediatric patient. J Pediatr 2000; 136:578.
- Mitsnefes MM, Kimball TR, Daniels SR. Office and ambulatory blood pressure elevation in children with chronic renal failure. Pediatr Nephrol 2003; 18:145.
- Chaudhuri A, Sutherland SM, Begin B, et al. Role of twenty-four-hour ambulatory blood pressure monitoring in children on dialysis. Clin J Am Soc Nephrol 2011; 6:870.
- Swartz SJ, Srivaths PR, Croix B, Feig DI. Cost-effectiveness of ambulatory blood pressure monitoring in the initial evaluation of hypertension in children. Pediatrics 2008; 122:1177.
- Stabouli S, Kotsis V, Toumanidis S, et al. White-coat and masked hypertension in children: association with target-organ damage. Pediatr Nephrol 2005; 20:1151.
- Kavey RE, Kveselis DA, Atallah N, Smith FC. White coat hypertension in childhood: evidence for end-organ effect. J Pediatr 2007; 150:491.
- Litwin M, Niemirska A, Ruzicka M, Feber J. White coat hypertension in children: not rare and not benign? J Am Soc Hypertens 2009; 3:416.
- Sorof JM, Poffenbarger T, Franco K, Portman R. Evaluation of white coat hypertension in children: importance of the definitions of normal ambulatory blood pressure and the severity of casual hypertension. Am J Hypertens 2001; 14:855.
- Mancia G, Bombelli M, Facchetti R, et al. Long-term risk of sustained hypertension in white-coat or masked hypertension. Hypertension 2009; 54:226.
- Lande MB, Meagher CC, Fisher SG, et al. Left ventricular mass index in children with white coat hypertension. J Pediatr 2008; 153:50.
- Lurbe E, Torro I, Alvarez V, et al. Prevalence, persistence, and clinical significance of masked hypertension in youth. Hypertension 2005; 45:493.
- Maggio AB, Aggoun Y, Marchand LM, et al. Associations among obesity, blood pressure, and left ventricular mass. J Pediatr 2008; 152:489.
- Soergel M, Kirschstein M, Busch C, et al. Oscillometric twenty-four-hour ambulatory blood pressure values in healthy children and adolescents: a multicenter trial including 1141 subjects. J Pediatr 1997; 130:178.
- Staessen JA, Bieniaszewski L, O'Brien E, et al. Nocturnal blood pressure fall on ambulatory monitoring in a large international database. The "Ad Hoc' Working Group. Hypertension 1997; 29:30.
- Litwin M, Simonetti GD, Niemirska A, et al. Altered cardiovascular rhythmicity in children with white coat and ambulatory hypertension. Pediatr Res 2010; 67:419.
- Flynn JT. Differentiation between primary and secondary hypertension in children using ambulatory blood pressure monitoring. Pediatrics 2002; 110:89.
- Sorof JM, Cardwell G, Franco K, Portman RJ. Ambulatory blood pressure and left ventricular mass index in hypertensive children. Hypertension 2002; 39:903.
- Belsha CW, Wells TG, McNiece KL, et al. Influence of diurnal blood pressure variations on target organ abnormalities in adolescents with mild essential hypertension. Am J Hypertens 1998; 11:410.
- Chamontin B, Amar J, Barthe P, Salvador M. Blood pressure measurements and left ventricular mass in young adults with arterial hypertension screened at high school check-up. J Hum Hypertens 1994; 8:357.
- Lurbe E, Invitti C, Torro I, et al. The impact of the degree of obesity on the discrepancies between office and ambulatory blood pressure values in youth. J Hypertens 2006; 24:1557.
- Urbina EM. Removing the mask: the danger of hidden hypertension. J Pediatr 2008; 152:455.
- Harshfield GA, Pulliam DA, Alpert BS. Ambulatory blood pressure and renal function in healthy children and adolescents. Am J Hypertens 1994; 7:282.
- Lubrano R, Travasso E, Raggi C, et al. Blood pressure load, proteinuria and renal function in pre-hypertensive children. Pediatr Nephrol 2009; 24:823.
- Patzer L, Seeman T, Luck C, et al. Day- and night-time blood pressure elevation in children with higher grades of renal scarring. J Pediatr 2003; 142:117.
- Yavuz S, Anarat A, Bayazıt AK. Ambulatory blood pressure monitoring in children with vesicoureteral reflux. Urology 2014; 83:899.
- Lurbe A, Redón J, Pascual JM, et al. Altered blood pressure during sleep in normotensive subjects with type I diabetes. Hypertension 1993; 21:227.
- Lurbe E, Redon J, Pascual JM, et al. The spectrum of circadian blood pressure changes in type I diabetic patients. J Hypertens 2001; 19:1421.
- Lurbe E, Redon J, Kesani A, et al. Increase in nocturnal blood pressure and progression to microalbuminuria in type 1 diabetes. N Engl J Med 2002; 347:797.
- Sorof JM, Poffenbarger T, Portman R. Abnormal 24-hour blood pressure patterns in children after renal transplantation. Am J Kidney Dis 2000; 35:681.
- Flynn JT. Ambulatory blood pressure monitoring should be routinely performed after pediatric renal transplantation. Pediatr Transplant 2012; 16:533.
- Díaz LN, Garin EH. Comparison of ambulatory blood pressure and Task Force criteria to identify pediatric hypertension. Pediatr Nephrol 2007; 22:554.
- Koshy S, Macarthur C, Luthra S, et al. Ambulatory blood pressure monitoring: mean blood pressure and blood pressure load. Pediatr Nephrol 2005; 20:1484.
- O'Sullivan JJ, Derrick G, Griggs PE, Wren C. Validation of the Takeda 2421 ambulatory blood pressure monitor in children. J Med Eng Technol 1998; 22:101.
- Belsha CW, Wells TG, Neaville WA, et al. Accuracy of the SpaceLabs 90207 ambulatory blood pressure monitor in children and adolescents. Blood Press Monit 1996; 1:127.
- Goonasekera CD, Wade AM, Slattery M, et al. Performance of a new blood pressure monitor in children and young adults: the difficulties in clinical validation. Blood Press 1998; 7:231.
- Procedural approach
- Interpretation of data
- - Normative data
- - Classification of BP
- INDICATIONS FOR ABPM
- White coat hypertension
- Masked hypertension
- Sustained hypertension and nocturnal nondipping
- Risk for cardiovascular disease
- Renal damage
- Our approach
- Defining ambulatory hypertension
- Technical limitations
- INFORMATION FOR PATIENTS