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

Measurement of Blood Pressure in Children and Adolescents Outside the Office for the Diagnosis of Hypertension

PURPOSE OF REVIEW

To review the benefits of ambulatory blood pressure monitoring and home blood pressure monitoring in children and to discuss implementation of guideline-recommended ambulatory blood pressure monitoring.

RECENT FINDINGS

Compared with office blood pressure, ambulatory blood pressure monitoring and home blood pressure monitoring provide superior accuracy, reproducibility, and stronger associations with target organ damage although future work is needed to determine the utility of home blood pressure monitoring to predict hypertension status on ambulatory blood pressure monitoring. Due to the benefits of out-of-office blood pressure measurement, ambulatory blood pressure monitoring has been recommended to confirm the diagnosis of hypertension in children and adolescents since publication of the 2017 American Academy of Pediatrics clinical practice guidelines on hypertension. However, access to ambulatory blood pressure monitoring remains limited to the subspecialty setting and novel care pathways are needed to improve guideline-concordant use of ambulatory blood pressure monitoring. Nocturnal home blood pressure monitoring may be a practical alternative when ambulatory blood pressure monitoring is not available.

Feasibility of home blood pressure screening in the paediatric outpatient clinic setting

OBJECTIVE

The aim of this study was to evaluate the acceptability and feasibility of home-based blood pressure (BP) screening in a group of paediatric patients with known elevated risk of developing hypertension.

DESIGN

Cross-sectional study.

SETTING

Specialist outpatient clinic and patient homes.

PATIENTS

52 children and adolescents living with neurofibromatosis type 1.

INTERVENTIONS

Clinic BP measured thrice manually and once via an automated device; home BP measured daily with the same device for 3 days.

MAIN OUTCOME MEASURES

Acceptability and feasibility were assessed with a Children's Anxiety Meter-State score, the comparability of home and clinic BPs, a parental survey, assessment of costs and the device return rate.

RESULTS

Home systolic BP and diastolic BP were statistically similar to both clinic manual (95% CI -4.78 to 0.13; -4.80 to 0.93) and automatic BPs (95% CI -4.44 to 2.08; -0.54 to 5.52). Anxiety scores (95% CI -0.57 to 0.35) were also similar between settings. Participants and their families reported that home BP measurement was easy, took ~10 min and minimally interrupted family life. Families also largely preferred home BP screening (73% 'yes', 23% 'not sure', 3% 'no'), and 90% returned their devices. Families reported substantial costs in attending clinic, which could be reduced with access to this home BP programme.

CONCLUSIONS

Home BP screening was acceptable and feasible, with home BPs comparable to clinic measurements, no associated anxiety and preferred by families. Telehealth with home BP screening is a viable alternative to in-person appointments, which could reduce individual costs, and foster greater equity of care and access to health services.

Clinical guidelines for the diagnosis, evaluation, and management of hypertension for Korean children and adolescents: the Korean Working Group of Pediatric Hypertension

Pediatric hypertension (HTN) is a significant, growing health concern worldwide and also in Korea. Diagnosis, evaluation, and treatment of HTN in Korean children and adolescents are uncertain due to limitations in using the current international guidelines, since the recommendations by the American Academy of Pediatrics (AAP) and European Society of Hypertension (ESH) guidelines differ. Furthermore, these are guidelines for Western youth, who are racially and ethnically different from Koreans. In addition, reference blood pressure values for all pediatric age groups, which are essential for the diagnosis of HTN according to these two guidelines, are absent in Korea. Therefore, HTN guidelines for Korean children and adolescents should be established. The Korean Working Group of Pediatric Hypertension established clinical guidelines for the diagnosis, evaluation, and management of HTN in Korean children and adolescents. These guidelines were based on reported clinical evidence, expert recommendations, and AAP and ESH guidelines. The characteristics of Korean youth and the Korean medical and insurance system were considered during the establishment of the guidelines. By providing recommendations suitable for Korean youth, these guidelines will help in the prevention and management of childhood HTN, thus relieving the burden of cardiovascular disease in adulthood in Korea.

Hypertension in children and adolescents: perspectives in Japan

Hypertension in children and adolescents is associated with increased risk of hypertension and cardiovascular disease (CVD) in adulthood. Therefore, preventing hypertension among children and adolescents is an important public health objective worldwide. Although the importance of hypertension in children and adolescents has increasingly been recognized, the field of research is relatively new and evidence for etiologies, prevention and treatment is sparse. This review mainly summarizes the content regarding hypertension in children and adolescents published in Hypertension Research in 2023/24. Highlights include the following: The prevalence of hypertension was higher in female than male Japanese junior high school students (13.7% vs. 4.7%), but there was no significant gender difference among Japanese senior high school students (7.4% vs. 5.4%). Hematological parameters, including red blood cell counts, hemoglobin counts, hematocrit and iron levels, were positively associated with blood pressure (BP) levels in healthy children and adolescents. Higher-risk longitudinal BP trajectories in early life were associated with increased risk of target organ damage (TOD) and higher combined TOD load in midlife. BP phenotypes (e.g., masked hypertension, white-coat hypertension) assessed using office and 24-h ambulatory BP monitoring were not highly reproducible in children. The salt check sheet was a useful tool for evaluating the approximate dietary salt intake in Japanese children and adolescents. It is recommended that healthcare providers screen for hypertension in children and adolescents and recognize the importance of early intervention for those with elevated BP levels. Beginning in childhood, continuous education on hypertension and proper dietary salt intake are key to reducing the risk of hypertension and decreasing the burden of CVD in adulthood.

Pediatric Blood Pressure and Cardiovascular Health in Adulthood

PURPOSE OF REVIEW

This review summarizes current knowledge on blood pressure in children and adolescents (youth), with a focus on primary hypertension-the most common form of elevated blood pressure in this demographic. We examine its etiology, progression, and long-term cardiovascular implications. The review covers definitions and recommendations of blood pressure classifications, recent developments in measurement, epidemiological trends, findings from observational and clinical studies, and prevention and treatment, while identifying gaps in understanding and suggesting future research directions.

RECENT FINDINGS

Youth hypertension is an escalating global issue, with regional and national variations in prevalence. While the principles of blood pressure measurement have remained largely consistent, challenges in this age group include a scarcity of automated devices that have passed independent validation for accuracy and a generally limited tolerance for ambulatory blood pressure monitoring. A multifaceted interplay of factors contributes to youth hypertension, impacting long-term cardiovascular health. Recent studies, including meta-analysis and sophisticated life-course modelling, reveal an adverse link between youth and life-course blood pressure and subclinical cardiovascular outcomes later in life. New evidence now provides the strongest evidence yet linking youth blood pressure with clinical cardiovascular events in adulthood. Some clinical trials have expanded our understanding of the safety and efficacy of antihypertensive medications in youth, but this remains an area that requires additional attention, particularly regarding varied screening approaches. This review outlines the potential role of preventing and managing blood pressure in youth to reduce future cardiovascular risk. A global perspective is necessary in formulating blood pressure definitions and strategies, considering the specific needs and circumstances in low- and middle-income countries compared to high-income countries.

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.

Ambulatory Blood Pressure Monitoring in Pediatrics, an Update on Interpretation and Classification of Hypertension Phenotypes

PURPOSE OF REVIEW

This review highlights the major changes reflected in the 2022 American Heart Association (AHA) Scientific Statement on Ambulatory Blood Pressure Monitoring (ABPM) in Children and Adolescents with a specific focus on the newly defined phenotypes of hypertension and their epidemiology and associated outcomes.

RECENT FINDINGS

The 2022 AHA guidelines' most notable changes include the following: (1) alignment of blood pressure (BP) thresholds with the 2017 American Academy of Pediatrics (AAP) clinical practice guidelines, 2017 American College of Cardiology (ACC)/AHA hypertension guidelines, and 2016 European Society of Hypertension (ESH) pediatric recommendations; (2) expansion of the use of ABPM to diagnose and phenotype pediatric hypertension in all pediatric patients; (3) removal of BP loads from diagnostic criteria; and (4) simplified classification of new hypertension phenotypes to prognosticate risks and guide clinical management. Recent studies suggest that utilizing the 2022 AHA pediatric ABPM guidelines will increase the prevalence of pediatric ambulatory hypertension, especially for wake ambulatory hypertension in older, taller males and for nocturnal hypertension in both males and females ≥ 8 years of age. The new definitions simplify the ambulatory hypertension criteria to include only the elements most predictive of future health outcomes, increase the sensitivity of BP thresholds in alignment with recent data and other guidelines, and thus make hypertension diagnoses more clinically meaningful. This guideline will also aid in the transition of adolescents and young adults to adult medical care. Further studies will be necessary to study ambulatory BP norms in a more diverse pediatric population and evaluate the impact of these guidelines on prevalence and future outcomes.

Joint statement for assessing and managing high blood pressure in children and adolescents: Chapter 1. How to correctly measure blood pressure in children and adolescents

The joint statement is a synergistic action between HyperChildNET and the European Academy of Pediatrics about the diagnosis and management of hypertension in youth, based on the European Society of Hypertension Guidelines published in 2016 with the aim to improve its implementation. The first and most important requirement for the diagnosis and management of hypertension is an accurate measurement of office blood pressure that is currently recommended for screening, diagnosis, and management of high blood pressure in children and adolescents. Blood pressure levels should be screened in all children starting from the age of 3 years. In those children with risk factors for high blood pressure, it should be measured at each medical visit and may start before the age of 3 years. Twenty-four-hour ambulatory blood pressure monitoring is increasingly recognized as an important source of information as it can detect alterations in circadian and short-term blood pressure variations and identify specific phenotypes such as nocturnal hypertension or non-dipping pattern, morning blood pressure surge, white coat and masked hypertension with prognostic significance. At present, home BP measurements are generally regarded as useful and complementary to office and 24-h ambulatory blood pressure for the evaluation of the effectiveness and safety of antihypertensive treatment and furthermore remains more accessible in primary care than 24-h ambulatory blood pressure. A grading system of the clinical evidence is included.

Hypertension in Children and Young Adults

Primary hypertension (PH) is most common during adolescence with increasing prevalence globally, alongside the epidemic of obesity. Unlike in adults, there are no data on children with uncontrolled hypertension and their future risk of hard cardiovascular and cerebrovascular outcomes. However, hypertension in childhood is linked to hypertensive-mediated organ damage (HMOD) which is often reversible if treated appropriately. Despite differing guidelines regarding the threshold for defining hypertension, there is consensus that early recognition and prompt management with lifestyle modification escalating to antihypertensive medication is required to ameliorate adverse outcomes. Unfortunately, many unknowns remain regarding pathophysiology and optimum treatment of childhood hypertension.

High blood pressure in children and adolescents: current perspectives and strategies to improve future kidney and cardiovascular health

Hypertension is one of the most common causes of preventable death worldwide. The prevalence of pediatric hypertension has increased significantly in recent decades. The cause of this is likely multifactorial, related to increasing childhood obesity, high dietary sodium intake, sedentary lifestyles, perinatal factors, familial aggregation, socioeconomic factors, and ethnic blood pressure (BP) differences. Pediatric hypertension represents a major public health threat. Uncontrolled pediatric hypertension is associated with subclinical cardiovascular disease and adult-onset hypertension. In children with chronic kidney disease (CKD), hypertension is also a strong risk factor for progression to kidney failure. Despite these risks, current rates of pediatric BP screening, hypertension detection, treatment, and control remain suboptimal. Contributing to these shortcomings are the challenges of accurately measuring pediatric BP, limited access to validated pediatric equipment and hypertension specialists, complex interpretation of pediatric BP measurements, problematic normative BP data, and conflicting society guidelines for pediatric hypertension. To date, limited pediatric hypertension research has been conducted to help address these challenges. However, there are several promising signs in the field of pediatric hypertension. There is greater attention being drawn on the cardiovascular risks of pediatric hypertension, more emphasis on the need for childhood BP screening and management, new public health initiatives being implemented, and increasing research interest and funding. This article summarizes what is currently known about pediatric hypertension, the existing knowledge-practice gaps, and ongoing research aimed at improving future kidney and cardiovascular health.

Discrepancies in the diagnosis of hypertension in adolescents according to available office and home high blood pressure criteria

This study aimed at comparing the prevalence of abnormal blood pressure (BP) phenotypes among 241 adolescents referred for hypertension (15.4 ± 1.4 years, 62% males, 40% obese) according to mostly used or available criteria for hypertension [AAP or ESH criteria for high office BP (OBP); Arsakeion or Goiânia schools’ criteria for high home BP monitoring (HBPM)]. High OBP prevalence was greater when defined by AAP compared with ESH criteria (43.5% vs. 24.5%; p < .001), while high HBPM prevalence was similar between Arsakeion and Goiânia criteria (33.5% and 37.5%; p = .34). Fifty‐five percent of the sample fulfilled at least one criterion for high BP, but only 31% of this subsample accomplished all four criteria. Regardless of the HBPM criteria, AAP thresholds were associated with lower prevalence of normotension and masked hypertension and greater prevalence of white‐coat and sustained hypertension than ESH thresholds. These findings support the need to standardize the definition of hypertension among adolescents.

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.

Nighttime Home Blood Pressure in Children: Association with Ambulatory Blood Pressure and Preclinical Organ Damage

[Figure: see text].

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.

Hypertension in Children and Adolescents: A Position Statement From a Panel of Multidisciplinary Experts Coordinated by the French Society of Hypertension

Hypertension is much less common in children than in adults. The group of experts decided to perform a review of the literature to draw up a position statement that could be used in everyday practice. The group rated recommendations using the GRADE approach. All children over the age of 3 years should have their blood pressure measured annually. Due to the lack of data on cardiovascular morbidity and mortality associated with blood pressure values, the definition of hypertension in children is a statistical value based on the normal distribution of blood pressure in the paediatric population, and children and adolescents are considered as having hypertension when their blood pressure is greater than or equal to the 95th percentile. Nevertheless, it is recommended to use normative blood pressure tables developed according to age, height and gender, to define hypertension. Measuring blood pressure in children can be technically challenging and several measurement methods are listed here. Regardless of the age of the child, it is recommended to carefully check for a secondary cause of hypertension as in 2/3 of cases it has a renal or cardiac origin. The care pathway and principles of the therapeutic strategy are described here.

Measurement of SBP at home by parents using hand-held Doppler device and aneroid sphygmomanometer: a single-centre experience

OBJECTIVE

We taught parents to use at home a hand-held Doppler device and aneroid sphygmomanometer for SBPmeasurement (HDBPM).

METHODS

Retrospective study including all children referred to evaluate hypertension over a 6-year period. Each child underwent HDBPM measurements performed by parents while awake over 2 weeks with three measurements performed twice daily.

RESULTS

Of n = 155 children, 145 (93.5%) were successful and aged median (interquartile range) 2.48 (1.01, 5.12) years, including 85 boys. Overall, there were 25, 19, 30 and 26% aged less than 1, 1 to less than 2, 2 to less than 5 and at least 5 years old, respectively. Seventy-eight (54%) had been referred for confirming diagnosis and 67 (46%) for ongoing monitoring of treated hypertension. Following HDBPM, 70 of 78 (90%) patients in the 'Diagnosis subgroup' were observed to have normal blood pressure (BP). In the monitoring subgroup, treated hypertension that required no medication changes was recorded in 35 of 67 (52%) and medication changed in 32 of 67 (48%), [increased, decreased or changed] in 22, 6 and 5%, respectively. In 10 of 67 (15%) medication was weaned and stopped completely following HDBPM. None of the children required admission to hospital to evaluate their BP level or manage hypertension.

CONCLUSION

Out-of-office BP monitoring using HDBPM is acceptable to children and families of young children when parents are taught to measure BP and supported by health professionals. We report evidence of the feasibility and clinical utility of HDBPM in a challenging population of children who are either too young or unable to tolerate 24-h ambulatory BP monitoring for both the diagnosis and ongoing management of clinically relevant hypertension.

Blood pressure measurement methodology and technology in the SWEET diabetes centers: An international SWEET database survey

INTRODUCTION

The accuracy of blood pressure (BP) measurement is a prerequisite for the reliable diagnosis and management of hypertension.

OBJECTIVES

This survey evaluated the use of office and out-of-office BP measurements and the antihypertensive pharmacological treatment in expert pediatric diabetes centers.

METHODS

A questionnaire was distributed in 78 reference pediatric diabetes centers of the SWEET international consortium. The methodology, devices, indications, and interpretation of office BP measurements (OBPM), 24-hour ambulatory BP monitoring (ABPM) and home BP monitoring (HBPM), and the preference for antihypertensive drug treatment was assessed. A grading score was developed to evaluate centers for overall BP measurement performance.

RESULTS

Fifty-two centers responded. The average score for OBPM methodology was 72.5%, for technology 77.5% and the overall center score was 74.75%.The majority of the centers used appropriate methodology and technology, however, there was heterogeneity among them. Manual auscultatory or automated devices specifically validated for children were used by 26/52 centers. ABPM was recommended by 35/52 centers (27/35 had health insurance coverage) and HBPM by 18/52 centers. The BP measurement methodology and devices used for ABPM and HBPM were frequently inadequate. Angiotensin converting enzyme inhibitors were the most frequently prescribed drugs for treating hypertension.

CONCLUSIONS

The majority of SWEET pediatric diabetes centers use adequate methodology and devices for BP measurement. ABPM is recommended by two thirds of the centers, whereas HBPM is less widely used. Further improvement in the quality of office and out-of-office BP measurements and harmonization among centers is necessary according to current guidelines.