Andersons pediatric cardiology 1599

Introduction
Systemichypertensionremainsoneofthemostcommoncardiovasculardiseases
inadults.Overthepastdecade,severalpublicationshavehighlightedthe
increasingprevalenceofhypertensioninchildrenandyoungpeopleandits
increasingpublichealthimportance,mirroringtheincreasingprevalenceof
childhoodobesity.Moreover,itisincreasinglyalsobeingrecognizedthat
childhoodbloodpressurelevelstrackintoadulthood,withabnormalblood
pressurelevelsduringchildhoodoftenresultinginhypertensionasyoungadults.
Thereisanongoingdebateregardingtheneedforscreeningforelevatedblood
pressureinasymptomaticchildrenasexpertgroupsmaintainthatpediatric
hypertension,overall,remainspoorlyrecognized.Primaryoressential
hypertensionisthemostcommonformofhypertensioninadults,butitis
becomingincreasinglyclearthattheoriginofthisconditionisinchildhoodand
nowaccountsforthemostcommoncauseofhypertensioninchildren10years
orolder.Theprevalenceofprimaryhypertensionduringchildhoodisincreasing,
inkeepingwiththeincreasingprevalenceofobesity.Secondaryhypertensionis
reportedlessfrequentlyinolderadolescents,althoughwhenpresentitresultsin
moreseverehypertension,oftenwithmoreimmediateclinicalconsequences,
andiscommonlycausedbyrenaldisease.Earlydetectionandcontrolnotonly
reducethegeneralmorbidityofhypertension,butalsoprotectthefunctionofthe
alreadydamagedkidney.Fortunately,recentpharmacologicadvancesenablethe
bloodpressuretobecontrolledinallpatients,withminimalundesirableside
effects.Consequently,themanagementofhypertensionisparticularlyrewarding
forthepracticingpediatrician.


EvaluationofBloodPressure:
Measurement,NormalValues,and
ImportantInfluences
MeasurementofSystemicBloodPressure
Measurementofbloodpressureinchildrenisusuallyfirstperformedatthetime

oftheirfirstpresentationtoapediatricdepartment,oraspartoftheirfirstschool
physicalexamination.Unfortunately,itisoftenomitted.Commonreasonscited
bycliniciansincludethepracticaldifficultiesinmakingmeasurementsininfants
andyoungchildren,changingnormativelimitsthroughoutchildhood,andthe
beliefthathypertensionisprimarilyanadultdisease.Thereareseveralaspectsto
measurementthatneedconsideration.Theseincludethetypeofmeasuring
machine,thetypeofcuffandbladder,thetechniqueofmeasurement,and
variablesrelatingtothepatient,theobserver,andtheenvironmentinwhichthe
measurementsaremade.

CuffandBladder
Thecuffistheinelasticcoveringthatencasesaninflatablerubberbladder.The
cuffisusuallymadeofcloth,usingsemisyntheticoranyothermaterialthatwill
reliablyandevenlytransmitpressureoverthearteryoncethebladderisinflated.
Acombinationthatallowsremovalofthebladderfromthecuffsothatthecuff
canbewashedatregularintervalsisprobablymoredesirable.1
Theinflatablebladder,ratherthanthecuff,needstobeofthecorrectsize.
Failuretoselectthecorrectsizeofbladderremainsthemostcommonerrorin
themeasurementofbloodpressure.“Miscuffing”referstotheinaccuracy
introducedasaresultofusingabladderthatistoosmallandnarrow,ortoolong
relativetothecircumferenceoftheupperarm.Itisadvisabletochooseasizeof
cuffinrelationtothecircumferenceofthearmasopposedtoitslength(Table
60.1).Althoughdebated,mostresearchersinthisareaagreethatthewidthfor
childrenshouldbeabout40%ofthecircumferenceoftheupperarm.2Thisis
becausemeasurementsmadeusingcircumferenceratherthanlengthasthe
yardstickcorrelatebestwithintra-arterialreadings.Inbothadultsandchildren,
theuseofcuffsthataretoosmallinlength,ortoonarrowinwidth,will


overestimatethepressuresmeasuredbyerrorsrangingfrom3over2to12over

8mmHg,withevengreaterrangesoferrorinobeseindividuals.3Thisis
sometimesreferredtoascuffhypertension.Toolargeacuffisalsorecognizedas
acauseofunderestimationofpressureinbothadultsandchildren.4–7Lengthof
thebladderismuchmoreimportantinchildrenthanadults,andalsoleadsto
overestimationofthemeasuredpressure.8
Table60.1
SuggestedSizesofSuitableSphygmomanometerCuffsforChildren
Newborns
Infants
1–5years
6–9years
10yearsandover
Obeseadults
Adultthigh

BladderWidth(cm)
4
6
8
10
13
15
18

BladderLength(cm)
5–10
12
15
20
23

30
36

ModifiedfromLeumanEP.Bloodpressureandhypertensioninchildhoodandadolescence.In:
FrickP,vonHarneckGA,MartiniGA,etal.,eds,AdvancesinInternalMedicineandPediatrics.
Berlin:Springer;1979:109–183.

Thesuggestedsolutiontotheproblemofthesizeofthecuffistohavearange
ofsizesofbladderavailable.IntheUnitedKingdom,cuffsandbladders
measuring4cminwidthand13cminlength,andthen8by18cm,12by18cm,
12by26cm,and12by40cm,areavailable.Theseusuallysufficeforarmsof
allsizesacrossthepediatricagerange,includingleanandobesechildren.Other
nationalsocietiesrecommenddifferentsizes.5Thebladdershouldbecentered
overthebrachialarteryandshouldencirclefrom80%toalloftheupperarm.5,8
Inpractice,thewidestcuffshouldbeusedtopermitauscultationofthe
antecubitalfossa.Clinically,toreduceerrorsrelatedtoissuesrelatedto
miscuffing,theauthorssuggestintroducingrecordingofcuffsizeinpatientcase
recordssothatsequentialmeasurementscanbecomparedinthesamepatient.

Instruments
Themercurysphygmomanometercombinedwithaninflatedcuffand
auscultationremainsthegoldstandardforthemeasurementofbloodpressurein
children.Widelyacceptedpercentilesfornormalpressuresthroughchildhood
havebeendevelopedusingsuchastandardmercurysphygmomanometer