Journal of Human Hypertension (2011) 25, 218–223
& 2011 Macmillan Publishers Limited All rights reserved 0950-9240/11
www.nature.com/jhh
ORIGINAL ARTICLE
Comparison of office, ambulatory and
home blood pressure in children and
adolescents on the basis of normalcy
tables
GS Stergiou1, N Karpettas1, DB Panagiotakos2 and A Vazeou3
1
Hypertension Center, Third University Department of Medicine, Sotiria Hospital, Athens, Greece;
Department of Nutrition—Dietetics, Harokopio University, Athens, Greece and 3First Department
of Pediatrics, P & A Kyriakou Children’s Hospital, Athens, Greece
2
In children and adolescents, the diagnosis of hypertension is based on office, home and ambulatory blood
pressure (BP) measurements. Different normalcy tables
for each method have provided 95th percentiles of BP as
thresholds for hypertension diagnosis. This study
assessed the differences in BP thresholds among these
methods when applied in the pediatric population. The
most widely used office, home and ambulatory BP
normalcy tables were compared in terms of the 50th
and 95th percentiles by gender and age. The range of
office BP change with increasing age is wider than for
home or ambulatory BP in boys and girls, apart from
systolic BP in boys. Percentiles of home BP are
consistently lower than that of daytime ambulatory BP.
There is a trend for office BP to be lower than home or
daytime ambulatory BP in the younger age subgroups.
This difference is progressively eliminated with increasing age, apart from systolic BP in boys. In conclusion, in
children and adolescents, the relationship between
office, home and ambulatory BP thresholds provided
by the widely used normalcy tables is not the same as in
the adults. These findings should be taken into account
when evaluating BP measurements in children and
adolescents in clinical practice.
Journal of Human Hypertension (2011) 25, 218–223;
doi:10.1038/jhh.2010.59; published online 3 June 2010
Keywords: children; adolescents; office blood pressure; home blood pressure; ambulatory blood pressure; normalcy
tables
Introduction
In children and adolescents, the thresholds for
hypertension diagnosis are based on the 95th blood
pressure (BP) percentiles for gender, age and height
derived from large cross-sectional studies of normalpopulation samples.1,2 As in the adults, because of
the phenomena of white coat and masked hypertension, office and out-of-office BP measurement (with
ambulatory monitoring or at home) is needed for the
precise diagnosis of hypertension in children.1–5
The recent guidelines by the European Society
of Hypertension for the assessment of children
and adolescents with elevated BP1 and by the
American Heart Association for the use of ambulatory BP monitoring in children6 stated that this
method is indispensable for the precise diagnosis of
Correspondence: Professor GS Stergiou, Third University Department of Medicine, Hypertension Center, Sotiria Hospital, 152
Mesogion Avenue, Athens 11527, Greece.
E-mail: [email protected]
Received 22 February 2010; revised 15 April 2010; accepted 24
April 2010; published online 3 June 2010
hypertension in children. Home BP monitoring is
also being used by practitioners for the assessment
of out-of-office BP in children,7,8 yet evidence on its
usefulness in the pediatric population has only
recently been reported.9
For the assessment of BP levels in the office, at
home and with ambulatory monitoring in children
and adolescents and the diagnosis of white coat,
masked and sustained hypertension in research and
in clinical practice, normalcy tables derived from
different studies are used.2,10–13 However, there are
differences in office, home and daytime and nighttime ambulatory BP thresholds derived from each
of these normalcy tables,2,10–13 which are mainly
attributed to inherent differences between these BP
measurement methods. Differences in the population samples included in the cross-sectional studies
that defined these normalcy tables might have
also contributed to the differences among the BP
measurement methods.
This paper compares the most widely used and
recommended by current guidelines normalcy tables
for office, ambulatory and home BP in children and
adolescents, aiming to assess differences in the BP
Blood pressure normalcy in children
GS Stergiou et al
219
Blood Pressure in Children and Adolescents.2
These tables provide BP percentiles per year of
age according to the percentiles of height. To
select BP percentiles for the same body size as in
the normalcy tables for home BP, we used
percentiles of height from the Centers for Disease
Control and Prevention growth charts14 that
correspond to the median height for each year
of age from 7 to 17 years in the participants of the
Arsakeion school database.13
thresholds of these measurement methods when
applied in the evaluation of individual children and
adolescents in clinical practice.
Methods
Normalcy tables and curves for office, ambulatory
and home BP in children and adolescents that are
proposed for clinical use by American and European
guidelines for pediatric hypertension were identified.1,2,6 For each BP measurement method (office,
home and ambulatory), the 50th and 95th percentiles by age (per year from 7 to 16 years), separately
for boys and girls and for systolic and diastolic BP
were selected. Percentiles were obtained from the
following normalcy tables:
(a) Ambulatory BP: normalcy tables derived by the
German study by Soergel et al.11,12 that have been
endorsed by both European1 and American
guidelines.2,6 The original report from this study
provided ambulatory BP percentiles by height.11
In more recent papers, percentiles by age (5–16
years) have been also provided.6,12 Percentiles
for the daytime and the nighttime period have
been provided, defined as 0800 to 2000 hours
and midnight to 0600 hours, respectively.
Ambulatory BP recording frequency was at
15–20 min during the day and 30–50 min during
the night.11
(b) Home BP: normalcy tables constructed from the
Arsakeion school study by Stergiou et al. in
Greece,13 which is the only study that provided
normative data for home BP measurements in
children and adolescents and has been endorsed
by the recent European Guidelines.1 In the
original paper, home BP percentiles have been
provided for 10-cm height subgroups.13 For the
purpose of this analysis, we developed new
normalcy tables (50th and 95th percentiles) by
age from the Arsakeion study database using the
same population and methodology as in the
original paper.13
(c) Office BP: normalcy tables included in the 4th
Report of the National High Blood Pressure
Education Program Working Group on High
This approach allowed the direct comparison of
the office, home and ambulatory BP percentiles for
boys and girls by age, as used when assessing
individual children and adolescents in clinical
practice.
Results
Data sets and percentiles
A comparison of the participants’ characteristics
and the BP measurement method used in the crosssectional studies that provided the normative data
for office, ambulatory and home BP used in this
analysis are presented in Table 1. The 50th and 95th
percentiles of home BP by age developed from the
Arsakeion school database13 for the purpose of this
analysis are shown in Table 2. The 50th and 95th
percentiles for office, home and daytime, nighttime
and 24-h ambulatory BP derived from the corresponding normalcy tables for each year of age (from
7 to 17 years), separately for boys and girls and for
systolic and diastolic BP, are presented in Figure 1.
Ambulatory BP
Data in Figure 1 suggest that daytime BP is by
4–7 mm Hg higher than 24-h BP and nighttime BP by
14–18 mm Hg lower than daytime BP. These differences are consistent in boys and girls assessed by
height or age and also for the 50th and the 95th
percentiles. There is a clear stepwise rise in systolic
ambulatory BP levels with increasing age (from 7 to
16 years) of 14–20 mm Hg in boys and 7–9 mm Hg
in girls. However, the corresponding changes in
Table 1 Characteristics of participants and measurement method in cross-sectional studies used to develop the normative tables for
blood pressure measurements in the office, at home and with ambulatory monitoring in children and adolescents
Blood
pressure
Year
published
(reference)
Country
Office
20042
US
Ambulatory
199711,12
Home
200713
No. of
subjects
Age
(years)
Gender
Male (%)
Female (%)
Measurement
method (device)
No. of
measurements
63 227
1–17
50.9
49.1
Auscultatory (mercury)
Single occasion
Germany
949
5–20
48.9
51.1
Oscillometric
(SpaceLabs 90207)
Days 36–48,
nights 7–9
Greece
778
6–18
46.0
54.0
Oscillometric
(Omron 705 IT)
12
Journal of Human Hypertension
Blood pressure normalcy in children
GS Stergiou et al
220
diastolic BP with increasing age are negligible
(1–3 mm Hg in boys and girls). These findings are
similar for the 50th and the 95th percentiles.
Home BP
Home BP is lower than daytime ambulatory BP by
4–8 mm Hg for systolic and diastolic BP in boys and
girls. These differences tend to be smaller regarding
the 95th percentiles. The range of the home BP
change with increasing age is similar as for ambulatory BP (for systolic BP, 15–21 mm Hg in boys and
6–11 mm Hg in girls and for diastolic BP, 1–4 mm Hg
in boys and girls).
Table 2 Percentiles for systolic/diastolic home blood pressure in
children and adolescents by age (Arsakeion school study)
Age
(years)
6
7
8
9
10
11
12
13
14
15
16
17
Percentiles for boys
Percentiles for girls
50th
95th
50th
95th
103/62
106/65
107/65
108/65
108/66
111/66
113/66
117/66
119/66
122/66
123/66
124/67
112/70
120/77
125/77
126/78
126/78
128/78
132/78
139/80
139/80
140/80
141/80
141/80
102/62
106/63
107/64
107/64
108/64
108/64
109/65
111/65
111/65
112/66
112/67
112/67
112/77
122/79
123/80
124/80
125/80
125/80
126/80
128/80
132/80
133/80
133/80
133/80
Office BP
The range of office BP change with increasing age
(from 7 to 17 years) is 14–17/7–9 mm Hg for systolic/
diastolic BP for boys and girls, which is wider than
for home or daytime ambulatory BP, apart from
systolic BP in boys. There is a consistent trend for
office BP to be lower than home or daytime
ambulatory BP in the younger age subgroups. This
difference seems to be progressively eliminated with
increasing age, apart from systolic BP in boys.
Boys versus girls
The comparative diastolic BP curves for 50th and
95th percentiles are very similar in boys and girls
(Figure 1). However, for systolic BP again there
seems to be no clear difference in the young
children, whereas the yearly steps of upwards shift
in the BP curves with increasing age were bigger in
boys (Figure 1), which represent the higher BP levels
in boys compared with girls during adolescence
with all measurement methods.
Discussion
This paper provides a comparison of office, home
and ambulatory BP in children and adolescents on
the basis of normalcy tables derived from large
cross-sectional studies. The 50th percentiles were
used to present the BP values at the midpoint of the
normal range and the 95th percentiles to provide the
BP thresholds for hypertension diagnosis. The main
GIRLS
BOYS
150
150
95th Percentiles
50th Percentiles
140
140
Systolic
BP
130
Systolic
BP
130
120
120
110
110
mmHg
mmHg
95th Percentiles
50th Percentiles
100
90
100
90
Diastolic
BP
80
Diastolic
BP
80
70
70
Age Categories
(years)
14
17
13
12
16
11
15
60
50
10
9
8
7
Age Categories
(years)
14
17
13
12
16
15
11
60
50
O
H
D
N 24h
O
H
D
N 24h
O
H
D
N 24h
O
H
D
10
9
8
7
N 24h
Figure 1 Comparison of 50th and 95th percentiles for office, ambulatory and home blood pressure in children and adolescents by
age2,11–13. BP, blood pressure; O, office BP; H, home BP; D, daytime ambulatory BP; N, nighttime ambulatory BP; 24 h, 24-h ambulatory BP.
Journal of Human Hypertension
Blood pressure normalcy in children
GS Stergiou et al
221
conclusion from these comparisons is that in
children and adolescents, the relationship between
office, home and ambulatory BP thresholds provided by widely used normalcy tables is not the
same as in the adults. Although this comparative
assessment has the limitation that the reported
office, home and ambulatory BP values have not
been obtained in the same population but were
derived from different studies, the BP thresholds
compared are recommended by current guidelines
to be used for decision making in individual
children and adolescents in clinical practice.1,2
The normalcy tables for ambulatory BP used in
this study have been developed by a study in
Germany11,12 and have been endorsed by the US
National High Blood Pressure Education Program
Working Group on high blood pressure in children
and adolescents,2 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 Research6 and the recent European Society
of Hypertension recommendations for the management of high BP in children and adolescents.1 The
normalcy tables used for home BP are the only ones
available derived from the Arsakeion school study
in Greece13 and have been endorsed by the recent
European Society of Hypertension recommendations for the management of high BP in children
and adolescents.1 For office BP, the US normative
data2 were preferred to the Man et al.10 normalcy
graphs, which have been based on pooled data from
six European countries (n ¼ 28 043). This choice was
made because the US tables have been derived from
a larger database (n ¼ 63 227), are the most widely
used normalcy tables in clinical practice and are the
recommended normalcy tables not only by the
American2 but also the recent European guidelines
for pediatric hypertension.1 Although the data sets
used for the development of normalcy tables for
office BP were much larger than those for home or
ambulatory BP (Table 1), the two latter methods are
known to have superior reproducibility15,16 to office/
clinic BP measurements reducing thereby the sample
size required. The major limitation in comparing the
percentiles of these normalcy tables is the fact that these
have been derived by studies of different populations,
yet this approach is recommended by current guidelines for the assessment of BP in individual children
and adolescents in clinical practice.
The rise in BP levels with increasing age in
children and adolescents is well known. This
analysis showed that home BP seems to have similar
ability as ambulatory monitoring to reveal the
change in BP levels with increasing age. This
applies for systolic and diastolic BP, yet for the
latter both methods revealed negligible changes
with increasing age. Interestingly, the range of office
BP levels across the age subgroups was considerably
wider than for home or ambulatory BP measurements (more evident for diastolic BP). One explana-
tion is that the effect of the office environment and
the observer on measured office BP is not the same
in all children and adolescents, which results to the
phenomena of white coat and the masked hypertension. These phenomena probably result in wider BP
range of office than out-of-office measurements
(home and ambulatory BP). On the other hand, it
might be argued that in children, the oscillometric
technique that was used to define the normal home
and ambulatory BP range (11–13) might be less
sensitive that the conventional auscultatory technique to reveal the diastolic BP changes with increasing age in children. Indeed, the SpaceLabs 90207
oscillometric ambulatory BP monitor that has been
used in the study that defined the normal range of
ambulatory BP11,12 has been validated in only one
study in children and adolescents and was found
accurate for systolic but not for diastolic BP
measurement.17 However, the oscillometric BP
monitor used in the Arsakeion school study that
defined the normal range of home BP in children has
been validated in a relative large study of children
and adolescents (n ¼ 197) and found to fulfill the
accuracy requirements of the European Society of
Hypertension International Protocol for systolic and
diastolic BP.18
The comparison of the two out-of-office BP
measurement methods (home and ambulatory BP)
is probably the most challenging finding of this
analysis. In contrast to the findings in the adults
in whom home BP levels are similar to daytime
ambulatory BP,15 in children and adolescents,
systolic and diastolic home BP seems to be significantly and consistently lower than daytime
ambulatory BP by 4–8 mm Hg. This difference is
largely unknown among physicians and is confirmed by the findings of a recent review of the few
available prospective pediatric studies that involved
both home and ambulatory BP monitoring.9 In the
ESCAPE trial in 118 children and adolescents with
chronic renal failure (78% on antihypertensive drug
treatment), mean home BP was by 6.4 mm Hg lower
than daytime ambulatory BP.19 Moreover, in a study
in 102 untreated children and adolescents referred
to a hypertension center for elevated BP (48%
without hypertension), home BP was lower than
daytime ambulatory BP by 10.6/3.3 mm Hg (systolic/
diastolic).20 Thus, both the normative tables derived
from different subjects and also direct comparison
trials in the same subjects suggest that in the
pediatric population, home BP is significantly lower
that daytime ambulatory BP, which is probably
attributed to the high level of physical activity in
the young population during the day.
Another challenging issue is the changing relationship of office with home BP with increasing age
(higher home than office BP in the younger children
with progressive elimination of this difference with
increasing age). No such phenomenon was observed
when the two out-of-office BP measurements (home
and ambulatory) were compared. The same pattern
Journal of Human Hypertension
Blood pressure normalcy in children
GS Stergiou et al
222
of changing office–home BP relationship with age
was found in the Arsakeion school study,21 where
both measurements have been obtained using the
same (oscillometric) device, which excludes any
influence due to different BP measurement technology (auscultatory for office BP versus oscillometric
for home and ambulatory BP). A plausible explanation provided in the Arsakeion study paper21 is that
children of different age are affected differently by
the office environment. Thus, the white coat reaction, which is regarded as an ‘alarm’ or ‘defense’
reaction, might be more prominent in the adolescents resulting in higher office than out-of-office BP
levels with increasing age.
In conclusion, a thorough comparison of normalcy
tables for office, home and ambulatory BP in
children and adolescents currently recommended
by current guidelines for clinical use, revealed
differences in the relationship between the BP
thresholds provided, as compared with the adults.
These findings should be taken into account in the
evaluation of office and out-of-office BP levels in
children and adolescents in clinical practice.
Further studies in large samples of children and
adolescents providing direct comparisons of office
and out-of-office BP measurements in the same
subjects are needed.
What is known about topic
K As in the adults, in children and adolescents both office
and out-of-office blood pressure measurements (home and
ambulatory) are needed for the accurate diagnosis of
hypertension.
K Recent European guidelines recommend the use of
normalcy tables for office, home and ambulatory blood
pressure measurements obtained by different studies.
2
3
4
5
6
7
8
9
What this study adds
K A comparison of the 50th and 95th percentiles of the most
widely used and recommended by current guidelines
normalcy tables shows that in children and adolescents, the
relationship between office, home and ambulatory blood
pressure thresholds is not the same as in the adults.
K In children and adolescents, home blood pressure seems
to be significantly and consistently lower than daytime
ambulatory blood pressure, whereas in adults no such
difference is found. Furthermore, there is a change in
the relationship between office and home blood pressure
with increasing age, with lower home values in the younger
children and a progressive elimination of this difference
in older children and in adolescents.
K These findings should be taken in account in the evaluation
of office and out-of-office blood pressure measurements
in clinical practice.
Conflict of interest
10
11
12
13
The authors declare no conflict of interest.
14
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