Ambulatory blood pressure status in children: comparing alternate limit sources

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The American Heart Association has included alternate ambulatory blood pressure (ABP) limits for children published by Wühl in 2002. These updated limits employ the same pediatric cohort data as the previous ABP limits published by Soergel in 1997 but differ in analysis technique. The implications of changing ABP limit source on the diagnosis of hypertension has yet to be examined in a large pediatric cohort. We reviewed 741 ABP monitorings performed in children referred to our hypertension clinic between 1991–2007. Hypertension was defined as 24-h mean blood pressure ≥ 95th percentile or 24-h blood pressure load ≥25%, by Soergel and Wühl limits separately. Six hundred seventy-three (91%) children were classified the same by both limit sources. Wühl limits were more likely than Soergel to classify a child as hypertensive (443 vs. 409, respectively). There was an increased classification of prehypertension and decreased white-coat hypertension by the Wühl method, whereas ambulatory and severe hypertension counts remained relatively the same by both limits sources. The use of either limit source will not significantly affect most clinical outcomes but should remain consistent over long-term research projects. Collection of new normative data from a larger, multiethnic population is needed for better measurement of ABP in children.

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  1. 1.

    Gimpel C, Wuhl E, Arbeiter K, Drozdz D, Trivelli A, Charbit M, Gellermann J, Dusek J, Jankauskiene A, Emre S, Schaefer F (2009) Superior consistency of ambulatory blood pressure monitoring in children: implications for clinical trials. J Hypertens 27:1568–1574

    CAS  Article  Google Scholar 

  2. 2.

    Clement DL, De Buyzere ML, De Bacquer DA, de Leeuw PW, Duprez DA, Fagard RH, Gheeraert PJ, Missault LH, Braun JJ, Six RO, Van Der Niepen P, O'Brien E, the Office versus Ambulatory Pressure Study Investigators (2003) Prognostic Value of Ambulatory Blood-Pressure Recordings in Patients with Treated Hypertension. N Engl J Med 348:2407–2415

    Article  Google Scholar 

  3. 3.

    Hansen T, Jeppesen J, Rasmussen S, Ibsen H, Torp-Pedersen C (2005) Ambulatory blood pressure and mortality: a population-based study. Hypertension 45:499–504

    CAS  Article  Google Scholar 

  4. 4.

    Sorof JM, Cardwell G, Franco K, Portman RJ (2002) Ambulatory blood pressure and left ventricular mass index in hypertensive children. Hypertension 39:903–908

    CAS  Article  Google Scholar 

  5. 5.

    Richey PA, Disessa TG, Hastings MC, Somes GW, Alpert BS, Jones DP (2008) Ambulatory blood pressure and increased left ventricular mass in children at risk for hypertension. J Pediatr 152:343–348

    Article  Google Scholar 

  6. 6.

    Stabouli S, Kotsis V, Rizos Z, Toumanidis S, Karagianni C, Constantopoulos A, Zakopoulos N (2009) Left ventricular mass in normotensive, prehypertensive and hypertensive children and adolescents. Pediatr Nephrol 24:1545–1551

    Article  Google Scholar 

  7. 7.

    Mitsnefes M, Flynn J, Cohn S, Samuels J, Blydt-Hansen T, Saland J, Kimball T, Furth S, Warady B (2010) Masked hypertension associates with left ventricular hypertrophy in children with CKD. J Am Soc Nephrol 21:137–144

    CAS  Article  Google Scholar 

  8. 8.

    Brady TM, Fivush B, Flynn JT, Parekh R (2008) Ability of blood pressure to predict left ventricular hypertrophy in children with primary hypertension. J Pediatr 152:73–78

    Article  Google Scholar 

  9. 9.

    Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL Jr, Jones DW, Materson BJ, Oparil S, Wright JT Jr, Roccella EJ (2003) Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Hypertension 42:1206–1252

    CAS  Article  Google Scholar 

  10. 10.

    Urbina E, Alpert B, Flynn J, Hayman L, Harshfield GA, Jacobson M, Mahoney L, McCrindle B, Mietus-Snyder M, Steinberger J, Daniels S (2008) Ambulatory Blood Pressure Monitoring in Children and Adolescents: Recommendations for Standard Assessment. Hypertension 52:433–451

    CAS  Article  Google Scholar 

  11. 11.

    Soergel M, Kirschstein M, Busch C, Danne T, Gellermann J, Holl R, Krull F, Reichert H, Reusz GS, Rascher W (1997) Oscillometric twenty-four-h ambulatory blood pressure values in healthy children and adolescents: a multicenter trial including 1141 subjects. J Pediatr 130:178–184

    CAS  Article  Google Scholar 

  12. 12.

    Wuhl E, Witte K, Soergel M, Mehls O, Schaefer F (2002) Distribution of 24-h ambulatory blood pressure in children: normalized reference values and role of body dimensions. J Hypertens 20:1995–2007

    Article  Google Scholar 

  13. 13.

    Cole TJ, Green PJ (1992) Smoothing reference centile curves: the LMS method and penalized likelihood. Stat Med 11:1305–1319

    CAS  Article  Google Scholar 

  14. 14.

    NHBPEP Working Group on High Blood Pressure in Children and Adolescents (2004) The Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents. Pediatrics 114:555–576

    Article  Google Scholar 

  15. 15.

    StataCorp (2009) Stata Statistical Software: Release 11. StataCorp LP, College Station

    Google Scholar 

  16. 16.

    Team RDC (2008) R: A language and environment for statistical computing. R Foundation for Statistical Computing, Vienna

    Google Scholar 

  17. 17.

    Litwin M, Niemirska A, Ruzicka M, Feber J (2009) White coat hypertension in children: not rare and not benign? Am J Hypertens 3:416–423

    Article  Google Scholar 

  18. 18.

    Mahan JD, Warady BA, Committee C (2006) Assessment and treatment of short stature in pediatric patients with chronic kidney disease: a consensus statement. Pediatr Nephrol 21:917–930

    Article  Google Scholar 

  19. 19.

    Jones D, Richey P, Alpert B (2009) Comparison of ambulatory blood pressure reference standards in children evaluated for hypertension. Blood Press Monit 14:103–107

    Article  Google Scholar 

  20. 20.

    Kuczmarski RJ, Ogden CL, Guo SS, Grummer-Strawn LM, Flegal KM, Mei Z, Wei R, Curtin LR, Roche AF, Johnson CL (2002) 2000 CDC Growth Charts for the United States: methods and development. Vital Health Stat 11:1–190

    Google Scholar 

  21. 21.

    Addo OY, Himes JH (2010) Reference curves for triceps and subscapular skinfold thicknesses in US children and adolescents. Am J Clin Nutr 91:635–642

    CAS  Article  Google Scholar 

  22. 22.

    Hadtstein C, Wühl E, Soergel M, Witte K, Schaefer F (2004) Normative values for circadian and ultradian cardiovascular rhythms in childhood. Hypertension 43:547–554

    CAS  Article  Google Scholar 

  23. 23.

    Portman R, McNiece K, Swinford R, Braun M, Samuels J (2005) Pediatric hypertension: diagnosis, evaluation, management, and treatment for the primary care physician. Curr Probl Pediatr Adolesc Health Care 35:262–294

    Article  Google Scholar 

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Correspondence to Cynthia S. Bell.

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Bell, C.S., Poffenbarger, T.S. & Samuels, J.A. Ambulatory blood pressure status in children: comparing alternate limit sources. Pediatr Nephrol 26, 2211–2217 (2011).

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  • Ambulatory blood pressure
  • Pediatric hypertension
  • Thresholds
  • Normative percentiles