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BLOOD PRESSURE MEASUREMENT IN CHILDREN. Mohammad Ilyas, M.D. Director Hypertension Clinic Arkansas Children’s Hospital Division of Nephrology, Department of Pediatrics. UAMS Little Rock. School Health Conference, Little Rock. Little Rock is the capitol of State of Arkansas A.False

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BLOOD PRESSURE MEASUREMENT IN CHILDREN

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BLOOD PRESSURE MEASUREMENT IN CHILDREN

Mohammad Ilyas, M.D.

Director Hypertension Clinic

Arkansas Children’s Hospital

Division of Nephrology, Department of

Pediatrics. UAMS Little Rock

School Health Conference, Little Rock


Little Rock is the capitol of State of Arkansas

A.False

B.True


Distribution of Hypertensive Patients


Tracking of Blood Pressure

  • Bogalusa Heart Study showed 40% individuals with SBP > 80th percentile at baseline had levels above that 15 years later

  • The ability to predict BP levels in adulthood from measurements in childhood would provide the opportunity to intervene before hypertension is established, thereby reducing the CVD risk.

    (Lane et al. J Human Hypertension 2004)


Overweight and Hypertension in Children

Ogden CL et al. JAMA 2002

Sorof JM et al. Pediatrics 2004


Blood Pressure, in children, is most commonly measured by:

A.Physicians

B.Nurses


Blood Pressure Measurement Training

  • Why to train already trained personnel?


Effect of Training on Observer Errors

Bruce NG et al. J Hypertens 1988; 6:375- 380


Outline

  • History (brief)

  • Blood pressure measurement devices

  • Procedure

  • Definition of hypertension

  • Practice cases


Blood Pressure Measurement

  • Stephen Hales 1733

  • Hollow glass tube in neck artery of horse

  • Blood rose 9 feet in glass tube

Medicine, an Illustrated History 1987


History of Blood Pressure Measurement

  • 1896. Scipione Riva-Rocci

  • Only Systolic BP measured by palpation

Medicine, an Illustrated History 1987


Blood Pressure Measurement - History

  • Cook and Briggs 1903

    • Residents, Johns Hopkins

    • Single size rubber bladder

    • Arm size a “small factor”

    • Systolic BP

      • Children75-90 (<2 yr) 90-110 (childhood)

      • Adults130 (men) 120 (women)

  • korotkoff


Devices


Which blood pressure apparatus is the “Gold standard” for BP measurement in children above age 3

A.DINAMAP

B.Oscillometric wrist BP monitor

C.Ambulatory BP monitor

D.Mercury sphygmanometer

E.Aneroid BP monitor


Mercury Sphygmomanometer


Mercury Sphygmomanometry

1998: EPA and the American Hospital Association agreed to virtually eliminate mercury from hospitals by 2005


In the absence of a mercury manometer, which is preferred method to measure BP in children above age 3

A.Oscillometric wrist BP monitor

B.Auscultatory aneroid BP monitor

C.Oscillometric arm BP monitor

D.DINAMAP


Aneroid Manometer

  • Mercury pressure gauge replaced by mechanical spring

  • Gauges are often small

  • Accuracy varies among manufacturers

  • Requires frequent calibration


Aneroid Manometers


Mercury and Aneroid Manometer


How often should an aneroid BP monitor be calibrated?

A.Once a day

B.Once a week

C.Once every 6 months

D.Once a year

E.Once every 5 years


Testing the Aneroid Manometer

  • Does the needle rest at zero?

  • Inflate to 200 mm Hg. Wait for 1 minute, if lower than 170 suspect leak

  • Using the Y connector, connect to mercury device and check readings

  • If any reading is off by >4 mm, remove from service

  • Date the calibration


Which is preferred method to measure BP in neonates and infants?

A.Oscillometric wrist BP monitor

B.Auscultatory aneroid BP monitor

C.Oscillometric finger BP monitor

D.DINAMAP

E.Mercury sphygmanometer


Oscillometric Devices

  • Office Use

    • Expensive (approximately $3000)

    • Many have been validated (BHS, AAMI)

    • Recommended for children of all ages

  • Home Use

    • Relatively inexpensive

    • Few have been validated in children

    • Not recommended for ages < 4 years


Dinamap® Oscillometric Device

  • Dinamap® is an acronym for:

    Device for

    Indirect

    Noninvasive

    Mean

    Arterial

    Pressure


Dinamap® Oscillometric Device

  • Dinamap® has been widely used in pediatrics

  • Detects MAP and estimates SBP and DBP

  • Proprietary algorithms

  • Accuracy decreases with increased arterial “stiffness”

  • Possible systematic errors in diabetics


What is being measured?

  • Auscultatory method: relies on relationship between audible Korotkoff sounds and pressure at systole and diastole

  • Oscillometric method: relies on the amplitude of oscillations in the arterial wall to determine MAP (maximum amplitude); complex and proprietary algorithms used to estimate SBP and DBP


Evaluation of the Dinamap 8100

  • Rose et al (2000)*

    • Noted from review of data from NHLBI studies that Dinamap algorithm skipped certain values

    • ARIC Study: More than 180,000 individual BP measurements

    • Never recorded SBP of 89, 119, 124, 125, 130, 140, 141, 150, 160, 170, 180, 190, 200 mmHg

    • No skip pattern for DBP

    • Skipped HR of 95, 99, 103, 106, 109 bpm

Rose KM et al Hypertens (2000); 35:1032-1036


Oscillometric Devices


Validated Monitors

  • British Hypertension Society

    • www.hyp.ac.uk/bhs/blood_pressure_list

  • Association for the Advancement of Medical Instrumentation (AAMI)

    • www.aami.org

  • dabl Educational trust

    • www.dableducational.com


Ambulatory BP Monitoring

  • Oscillometric or acoustic methods

  • 24 hour monitoring

  • Individual measurements not more accurate

  • Readings downloaded into PC

  • Cost: $2500-4500


Ambulatory Blood Pressure Monitoring


White Coat Hypertension


Ambulatory Blood Pressure Monitoring


Procedure


What effect would you expect when taking the blood pressure on an obese child with a small BP cuff?

A. No effect

B. Higher blood pressure

C. Lower blood pressure


Case History

  • 12 years old boy

  • Admitted for cellulitis of left lower leg

  • BP= 210/110 mm Hg

  • Blood pressure rechecked

  • Physical examination, Wt. 587 pounds


Blood Pressure Cuff size


Blood Pressure Cuff Size

Index line

Cuff length = 80% of MAC

Bladder length (80%)

20%

Cuff width = 40% of MAC

MAC

Largest allowable mid arm circumference for bladder (100%)


Blood Pressure Cuff SizeNHANES 99-2002 Children

(%)

35% of 4th and 8th graders needed large adult cuff in Marianna


Recommended Dimensions for BP Cuff Bladders


Blood pressure is measured in children preferably on

A.Right lower leg

B.Left upper arm

C. Right upper arm

D.Left wrist

E.Right wrist


What is the optimal position for a patient’s arm to be in when taking the blood pressure?

A.Cubital fossa at the heart level

B.Elbow at heart level

C.Elbow supported with midpoint of upper arm at heart level

D.Elbow by the side of the body


Auscultatory MethodFourth Report on BP in Children 2004

  • Sitting quietly for 5 minutes

    • Back supported and feet on the floor

  • Right arm supported, cubital fossa at heart level

  • Estimate systolic BP by palpation, re-inflate cuff to 20 mmHg higher

Pediatrics. August 2004


What is the optimal rate of deflation of blood pressure cuff?

A.1 mm Hg / sec

B.2-3 mm Hg / sec

C.5 mm Hg / sec

D.10 mm Hg / sec


Auscultatory MethodFourth Report on BP in Children 2004

  • Deflate cuff at 2-3 mmHg/sec

  • Systolic BP= onset tapping sounds*

  • Diastolic BP= disappearance of sounds (fifth Korotkoff sound)

  • Record BP twice on each occasion as right arm, sitting, SBP/DBP(K5), average used to estimate BP level

Pediatrics1996;98:649-658


Auscultatory Sounds


Auscultatory MethodFourth Report on BP in Children 2004

  • DBP is determined by disappearance of Krotkoff sounds (K5)

  • Sometime Krotkoff sounds heard till 0 mm Hg

    • Try less pressure on the head of stethoscope

    • If K5 still persists K4 should be recorded as DBP

Fourth report on BP. Pediatrics August 2004


Blood Pressure In Children

  • Auscultation is preferred method

  • Elevated BP must be confirmed on repeated visits

  • BP readings >90th obtained by oscillometric devices, should be repeated by auscultation

Fourth report on BP. Pediatrics August 2004


Definition


Hypertension- Definition

  • Normal blood pressure: less than 120/ 80 mmHg

  • Pre-hypertension: 120 – 139/ 80 - 89 mmHg

  • Hypertension:

    Stage 1: 140 to 159 /90 to 99 mmHg

    Stage 2: 160 mmHg / 100 mmHg

    The JNC 7 report. JAMA 2003; 289:2560.


Pediatric BP Standards

  • Blood pressure correlates with:

    Age

    Gender

    Height percentile

  • Standards

    Ages 1-12 months: 1987 task force

    Ages 1-17 years: Fourth BP report

Fourth report on BP. Pediatrics August 2004


Definitions

  • Normal

    • SBP and DBP <90th percentiles for gender, age, and height

  • Pre-hypertension

    • Average SBP or DBP between 90th and 95th percentiles or > 120/80 mm Hg

  • Hypertension

    • Average SBP and/or DBP > 95th for gender, age, and height on more than 3 occasions

Fourth Report on BP. Pediatrics August 2004


5 yrs old

Girl

BP 121/80

Height 90th

percentile

90th :

109/69

95th :

112/73

Fourth Report on BP. Pediatrics August 2004


Definitions

  • Stage I hypertension

    • Average SBP and/or DBP between 95th and 99th percentile plus 5 mm Hg

  • Stage II hypertension

    • Average SBP and/or DBP > 99th percentile plus 5 mm Hg

Fourth Report on BP. Pediatrics August 2004


5 yrs old

Girl

BP 121/80

Height 90th

percentile

90th :

109/69

95th :

112/73

99th :

120/81

Stage II:

>125/86

Fourth Report on BP. Pediatrics August 2004


A 7 years old boy had average BP 110/60 mm Hg. Similar BP readings were documented on three separate occasions. His height is at 95th percentile. This boy has

A.Normal blood pressure

B.Pre-hypertension

C.Stage I hypertension

D.Stage II hypertension


A 8 years old girl has average BP 130/90 mm Hg. Similar BP readings were documented on three separate occasions. Her height is at 75th percentile This girl has

A.Normal blood pressure

B.Pre-hypertension

C.Stage I hypertension

D.Stage II hypertension


A 11 years old boy had average BP 140/95 mm Hg. Similar BP readings were documented on three separate occasions. His height is at 5th percentile This boy has

A.Normal blood pressure

B.Pre-hypertension

C.Stage I hypertension

D.Stage II hypertension


A 18 years old young man had average BP 150/95 mm Hg. Similar BP readings were documented on three separate occasions. His height is at 50th percentile This young man has

A.Normal blood pressure

B.Pre-hypertension

C.Stage I hypertension

D.Stage II hypertension


Blood Pressure Screening in Marianna

  • May 2005

  • Volunteers and school nurse was trained for BP measurement

  • 81, 4th grader (89% AA)

  • First screening

    • Normal80%

    • Pre-htn9%

    • Hypertension11%

  • Third screening

    • Hypertension3.7%


School Blood Pressure Screening

  • Purpose

    • To find undiagnosed hypertensive school children and adolescents

    • Refer these children to primary care physicians

    • Help primary care physicians in the management of these children if required


Summary

  • Accurate blood pressure measurement is the corner stone of diagnosis of hypertension in children

  • Oscillatory method can be used for screening but elevated blood pressure should be confirmed with auscultatoy method

  • Appropriately sized cuff is mandatory and measure mid arm circumference to choose the cuff size

  • Calibrate BP measurement apparatus semiannually


Thanks

  • Ms. Paula Smith

  • Department of Pediatrics-UAMS

    • Office of education

  • Minority Health Commission

  • Marianna School


Hypertension Clinic-ACH

  • Dr. Karen McNiece, M.D

  • Dr. Thomas Wells, M.D.

  • Dr. Mohammad Ilyas, M.D.

  • Jona Plummer, RNP

  • Wendy Davis, RN

    Contact Number

    (501) 364-1847


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