Blood Pressure Monitoring in Children, Pregnancy, and Chronic Kidney Disease

  

Percentiles for boys (n = 347)

 

Percentiles for girls


(n = 420)


Height (cm)


N


50th


95th


N


50th


95th


120–129


23


105/64


119/76


36


101/64


119/74


130–139


51


108/64


121/77


51


103/64


120/76


140–149


39


110/65


125/77


61


105/65


122/77


150–159


41


112/65


126/78


71


108/66


123/77


160–169


45


115/65


128/78


148


110/66


124/78


170–179


91


117/66


132/78


46


112/66


125/79


180–189


57


121/67


134/79


7


114/67


128/80




Instructions for home BP monitoring in children and adolescents are shown in Table 13.2 [5]. Use of automated electronic (oscillometric) upper-arm devices that have been successfully validated specifically in children is recommended. Moreover, using devices with automated memory or PC-link capacity avoids potential reporting bias with over- or underreporting of home BP readings. A 6- to 7-day (minimum 3-day) schedule with duplicate morning (before drug intake if treated) and evening home BP measurements taken in the sitting position after few minutes rest is currently suggested since this is in line with the recommendation in adults and this has been validated in children and adolescents [17]. The average value of all measurements after discarding the first day is used for the BP assessment. This schedule should be performed for the initial diagnosis in children with suspected hypertension as complementary to ambulatory BP monitoring, and also before each follow-up visit to the doctor in children with treated hypertension. In the long-term monitoring of children treated for hypertension, 1–2 home measurements per week between office visits, or even less frequent, might suffice [5].


Table 13.2

Instructions for home blood pressure monitoring in children and adolescents (permission from [5])


































Devices


• Use automated electronic (oscillometric) upper-arm devices that have been successfully validated specifically in children


• Ensure the appropriate cuff size for the individual’s arm circumference is utilized


• Select devices equipped with automated memory or PC link capacity when available


Conditions


• Measurements may be taken by parents of young children, or self-measurements may be appropriate for some adolescents


• Perform measurements in a quiet room after 5 min of rest in the seated position with back supported and arm resting at heart level


Schedule


• Monitor home blood pressure for no less than 3 routine school days but preferably 6–7 days


• Obtain duplicate morning and evening measurements (with 1 min intervals) on each day BP is monitored


Interpretation


• Calculate the average of all measurements after discarding the first day


• Evaluate the average value using the available normalcy data for home blood pressure in children


• Average home blood pressure ≥95th percentile for gender and height indicates home hypertension


In conclusion, home BP monitoring in children appears to be superior to office BP due to several advantages, including the detection of white-coat and masked hypertension, lack of observer error and bias, and higher reproducibility. However, since the current evidence for ambulatory BP monitoring in children is much stronger, this method should have the primary role in diagnosis, with home BP monitoring being used if ambulatory monitoring is not available or not tolerated. Data on the optimal home BP monitoring schedule, and normalcy tables with thresholds (percentiles) for home hypertension diagnosis are now available but the evidence on the relationship with preclinical target-organ damage and validation of electronic home monitors in children is limited. Accumulating data will probably allow home BP monitoring to acquire an evidence-based role in wide clinical application in children and adolescents in near future.


13.2 Home Blood Pressure Monitoring in Pregnancy



A. Shennan

Measuring BP in pregnancy has unique importance and its own specific challenges [18]. It is fundamental to both detecting and managing hypertension in pregnancy, which can have acute implications for both mother and baby. Hypertension maybe a sign of preeclampsia, a leading cause of maternal mortality (14%) and preterm birth (20%) globally [19]. Preeclampsia, characterized by hypertension, is often asymptomatic, even if severe, and BP measurement is the hallmark of identification. One-quarter of all stillbirths and neonatal deaths are attributed to this disease in low and middle income countries. If left unrecognized, life-threatening disease invariably ensues, usually within 2 weeks. Measuring BP will identify those who need monitoring and delivery, and indicate those who require therapy to reduce the risk of cerebrovascular events. When correctly managed, preeclampsia deaths are largely avoidable [20]. The implications of over or missed diagnosis are substantial and therefore correct BP measurement is key to safe management.


BP should be measured at every antenatal visit. However, even antenatal schedules may not be sufficiently frequent to identify fulminant preeclampsia where onset and progress can be rapid and often asymptomatic. The potential for home monitoring to assist in identification and management is therefore substantial.


Care in technique and correct cuff size is similar to all patients, but specifically aortocaval compression should be avoided when lying supine in the third trimester by left lateral tilt. Sitting is an appropriate instruction for those using home monitors. Korotkoff fifth sound should be used for auscultation in determining diastolic BP [21] if used in clinic to compare with home assessment to elucidate white-coat effects. The vasodilatation of pregnancy does not alter the accuracy of the fifth Korotkoff sound, and home BP devices should be validated to this diastolic endpoint. Digit preference is common among midwives at initial assessment and threshold avoidance must be avoided given the possible severe implications of even mild hypertension in pregnancy. Home monitoring helps eliminate these errors.


Oscillometric monitors do under record the BP in preeclampsia, and often by significant amounts (>10 mmHg). This is related to the decreased arterial compliance, the reduced intra-vascular volume in preeclampsia and the interstitial edema which affect the amplitude and detection of the oscillometric waveform [18]. As each algorithm is unique, every device should be validated in pregnancy, once the device has passed an adult validation. Some companies have a generic algorithm that is suited to pregnancy (e.g., Microlife and Omron) and therefore have a few models suited for use, and most of these are appropriate for home monitoring. Accuracy assessment in pregnancy must include both women with preeclampsia (n = 15) and women with a range of BPs (n = 30). The Cradle VSA also has a traffic light warning system for both high and low BP, where the shock index (Heart rate/Systolic BP) has been shown to reliable detect shock associated with obstetric hemorrhage and sepsis [22]. The traffic light can be useful for home monitoring as provides a simple action point for patients. The Cradle VSA can also be used as a manometer with an auscultatory technique if clinicians want to confirm unusual results. The devices that have been validated for use in pregnancy are shown in Table 13.3.
Oct 30, 2020 | Posted by in Uncategorized | Comments Off on Blood Pressure Monitoring in Children, Pregnancy, and Chronic Kidney Disease
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