Annals of Medicine
ISSN: 0785-3890 (Print) 1365-2060 (Online) Journal homepage: http://www.tandfonline.com/loi/iann20
Blood Pressure in Children, Adolescents and Young Adults Matti Uhari, E. Matti Nuutinen, Juha Turtinen, Tytti Pokka, Vesa Kuusela, Hans K. Åkerblom, Matti Dahl, Eero A. Kaprio, Erkki Pesonen, Matti Pietikäinen, Matti K. Salo & Jorma Viikari To cite this article: Matti Uhari, E. Matti Nuutinen, Juha Turtinen, Tytti Pokka, Vesa Kuusela, Hans K. Åkerblom, Matti Dahl, Eero A. Kaprio, Erkki Pesonen, Matti Pietikäinen, Matti K. Salo & Jorma Viikari (1991) Blood Pressure in Children, Adolescents and Young Adults, Annals of Medicine, 23:1, 47-51, DOI: 10.3109/07853899109147930 To link to this article: http://dx.doi.org/10.3109/07853899109147930
Published online: 08 Jul 2009.
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Date: 29 March 2016, At: 21:55
Special Section: Cardiovascular Risk in Young Finns
Blood Pressure in Children, Adolescents and Young Adults
Downloaded by [University of Newcastle] at 21:55 29 March 2016
Matti Uhari’, E. Matti Nuutinenl, Juha Turtinen’, Tytti Pokkal, Vesa Kuusela2, Hans K. Akerblom3, Matti Dah14, Eero A. Kaprio5, Erkki Pesonen5, Matti Pietikainen6, Matti K. Salo7 and Jorma Viikari*
The question of whether blood pressure i s one of the main risk factors for cardiovascular diseases in childhood has been evaluated in a Study of Cardiovascular Risk in Young Finns. In the second follow-up study, carried out in 1986, blood pressure was successfully measured in 2500 individuals aged nine to 24 years using a random zero sphygmomanometer. The mean systolic blood pressure in girls rose from 102 mmHg (95th percentile 119 mmHg) at age nine to 116 mmHg (138 mrnHg) at age 24 and that in boys from 102 mmHg (95th percentile 121 mmHg) to 128 mmHg (148 mmHg). Diastolic blood pressure was more often measurable using Korotkoff’s 5th than the 4th phase. The values observed were similar to those reported by the Second Task Force on Blood Pressure Control in Children, but owing to differences in the methods used to measure blood pressure it cannot be reliably concluded that the blood pressures were similar i n the two series. Even in childhood blood pressure measurement is important, and since it changes with the physical size of the child, observations should be compared with normal values such as those reported here. No data are yet available to suggest that children with blood pressure values in the high normal range would benefit from interventions. Thus normal blood pressure value curves should be applied with caution when assessing children. Key words: blood pressure; normal values. (Annals of Medicine 23: 47-51,
1991)
Introduction The measurement of arterial blood pressure (BP) is an easy method of assessing the condition of the heart and circulatory system. BP is an important predictor of future cardiovascular diseases in adults ( l ) , but whether it has a similar predictive value in childhood remains an open question. Screening for hypertension has been considered unnecessary in childhood (2, 3), and opinions vary on whether to measure the BP of children attending for
From the ’Department of Pediatrics, University of Oulu, Oulu, *Central Statistical Office of Finland, Helsinki, Children’s Hospital, 5First and %econd Department of Pediatrics, University of Helsinki, Helsinki, ‘Department of Pediatrics, University of Turku, 8Department of Medicine, University of Turku. Turku, 6Department of Pediatrics, University of Kuopio, Kuopio, and ‘Department of Pediatrics, University of Tampere, Tampere, Finland. Address and reprint requests: Matti Uhari, M.D., Department of Pediatrics, University of Oulu, SF-90220 Oulu, Finland. 4
regular health visits (2, 3). For clinical purposes it is important to measure BP in sick children and to monitor the child carefully if high values are recorded. Blood pressure in children changes with age and physical size and thus a BP value should be compared with normal curves before deciding on its normality. Normal BP curves are available from the United States of America and from surveys performed in Europe (3, 4). The Second Task Force on Blood Pressure Control in Children pooled the data available from large surveys of normal BP in children, using the first BP measurement to calculate normal curves. Korotkoff’s 4th phase (K4) was used as the marker of diastolic BP under the age of 13 and the 5th phase (K5) from the age of 13 onwards (3). These curves have been criticised for being hard to read and because the switch between the Korotkoff phases according to the age of the child is difficult to accomplish reliably in clinical practice. Children’s BP was one of the main risk factors for cardiovascular diseases measured and monitored in the Study of Cardiovascular Risk in Young Finns. We report here the trends in BP with changes in age, height and weight and compare our values with those
Uhari Nuutinen Turtinen et al.
48
Results and Discussion
Downloaded by [University of Newcastle] at 21:55 29 March 2016
published by the Second Task Force on Blood Pressure in children and young adults.
Systolic BP rose steadily with age in boys and girls (Fig. l), with the rise of diastolic less than that of systolic BP but nevertheless continuous (Fig. 2). The Subjects and Methods systolic BP values were similar to those reported by the The sampling procedure has been described elsewhere Task Force (Fig. 1). To make comparison between the (5). The cross-sectional survey in 1980 involved mea- diastolic BP curves possible it was necessary to use surement of BP in 3012 subjects using a mercury the K4 phase as the marker of diastolic BP in children sphygmomanometer, while three years later only those under 13 and K5 for children over 13 (Fig. 3). The who had participated in 1980 were invited, and BP was diastolic BP when measured using K4 was somewhat measured in 2887 cases. At the second follow-up in higher than the figures published by the Second Task 1986 BP readings were obtained from 2500 individuals. Force, but those measured according to K5 were lower Blood pressure was measured with an ordinary (Fig. 3). This was especially true for the 95 percentile sphygmomanometer on the first two occasions, and curve (Fig. 3). The Task Force on Blood Pressure Control in Chilwith a random zero sphygmomanometer (RZS) in 1986. It was measured after at least three minutes’ rest using dren pooled results of several reports on normal values the right arm, the subjects being seated with their hand for BP in childhood (3),taking the first BP measurement resting on the table. Two cuff sizes, 9.5 x 28 cm and 13 as the final value in the analysis. The measurement of x 40 cm (depending on the size of the subject’s arm), BP is highly vulnerable to many biases, including the were used in order to cover at least two thirds of the terminal digit preference of the observer, and thus upper arm. Readings were taken to the nearest even comparisons between results may be misleading and number of millimeters of mercury and were performed should be performed only if RZS measurements have three times on each subject. Korotkoff’s first phase (KI) been used. The Task Force survey used an ordinary was used as the sign of systolic BP, and both K4 and sphygmomanometer. It has been found that RZS values tend to be lower than those measured with an K5 as indicators of diastolic BP. Each survey employed five measurement groups with ordinary device (7), and thus, although the present BP one nurse in each responsible for BP measurements. curves turned out to be very similar to those published Altogether 11 nurses participated in the three surveys by the Task Force, it is impossible to conclude reliably in 1980 to 1986. The first cross-sectional series of BP from the data available whether the BP in Finnish children and young adults is really similar to the values values has been published elsewhere (6). published by the Second Task Force (3).
SYSTOLIC BP
SYSTOLIC BP GIRLS
150
140
c
BOYS
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. -0
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I
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18
---I1 21
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t
AGE, YEARS
Figure 1. Systolic blood pressure mean curve (lower) and 95th percentile curve (upper) in relation to age in girls and boys in the Study of Cardiovascular Risk in Young Finns (I) as compared with the curves published by the Second Task Force (11)(3).
A n n AAnd 9Q
Blood Pressure in Childhood
Downloaded by [University of Newcastle] at 21:55 29 March 2016
90
50
49
I
90
-
The recommendation to use K4 instead of K5 as the indicator of diastolic BP in children under the 13 was based on the assumption that the K5 phase is far too often lacking in children (3). Our results suggest, however, that the K4 phase is absent more often than K5, the latter being missing in 1.1 % of the subjects at most, and that diastolic BP can be measured in all children using the K5 phase (Uhari M, Nuutinen EM, Turtinen J, Pokka T, unpublished observations). The occurrence of a K5 pulse sound depends directly on the pressure applied to the stethoscope head ( 8 ) , and nurses measuring BP in children should be trained to use as little pressure as possible. The rise in BP with increasing age is most probably caused by the growth of the child. Thus the normal curves should be plotted against the height or weight of the child rather than the age. The rise in systolic BP when plotted against height or weight was steeper in boys than in girls (Figs. 4, 5), and there was a drop in the curve when the weight of the child (of either sex) increased above 80 kg. This finding is, however, based on only a few observations (Fig. 5). The Study of Cardiovascular Risk in Young Finns is
Figure 3. Diastolic blood pressure mean curve (lower) and 95th percentile curve (upper) in relation to age in girls and boys in the Study of Cradiovascular Risk in Young Finns (I) as compared with the curves published by the Second Task Force (11)(3). Diastolic blood pressure was measured according to Korotkoffs 4th phase in children under the age of 13 years and Korotkoff's 5th phase in older children.
50
DIASTOLIC EP rnm Hg
GIRLS
5 6
7
8
9 10 11 12 13 14 15 16 17 18 19 2 0 21 22 23 24
DIASTOLIC BP mm Hg
80 90
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-
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/#A
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---
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a longitudinal survey in which the same individuals have been followed up since 1980 in three crosssectional series of measurements three years apart. Blood pressure was measured using an ordinary
1
I
1
I
1
1
I
I
I
sphygmomanometer on the first two occasions (6, 9), giving values somewhat lower than those observed in earlier surveys (6, 9) and involving substantial measurement errors caused by the observer on the first
BLOOD PRESSURE
BLOOD PRESSURE mm HQ
GIRLS
BOYS
160
140
‘---
130
--
100
0 -
/ e O
/
90 80
-
70
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60
60
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1
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I
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,
,
100 110
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4 50
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,
J
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30
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50
60
70
80
90 100 110
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Figure 5. Mean systolic (--) and diastolic (-) blood pressure curves (lower) and 95th percentile curve (upper) in relation to weight in girls and boys in the Study of Cardiovascular Risk in Young Finns.
Am-
14-A 0.3
Downloaded by [University of Newcastle] at 21:55 29 March 2016
Blood Pressure in Childhood occasion (10). Thus the observed fall in BP is more probably attributable to the measuring device and measurement errors in the earlier values than to any real fall in BP during the period in question. Hypertension in its early stages is poorly understood, but blood pressure rises with age in childhood. This rise, a consistent finding in the western world (3), has been attributed to the physical growth of the child and thus interpreted as a physiological phenomenon. Nevertheless, there are some primitive cultures in which BP remains at almost the same level throughout life (11). Thus it may be that the rise in BP is actually a part of the early natural history of hypertension (12). Long-term longitudinal surveys of BP starting from childhood would be needed to test this hypothesis. High BP and hypertension are hard to define in childhood. The most commonly used definition is a statistical one which states that all those individuals with BP values above two standard deviations or above the 97.5th percentile, for example, are hypertensive. This means that we accept hypertension as occurring at the same frequency even in neonates, i.e. in about 2.5% of the children. Hypertension in childhood is most often secondary in nature, however, and in these patients their BP is so high that there are hardly any difficulties in defining the sick child as hypertensive (13). Thus normal BP curves should be used cautiously in practice, and no data are presently available to show that children with high normal BP values would benefit from any kind of intervention. It may well be that definitions of hypertension in terms of certain limit values such as 160/90 mmHg are as useful with children as with adults. Although RZS is not usually available in ordinary clinical circumstances, and although it gives somewhat lower BP values than an ordinary mercury sphygmomanometer (7), we suggest that the present normal value curves are more accurate, even for everyday clinical practice, than curves based on ordinary sphygmomanometer measurements. In clinical practice the findings in one individual are being compared to normal curves, and the process is not biased by small deviations in mean values between groups. We thank the Academy of Finland (Medical Research Council, National Research Council for Agriculture and Forestry), the Red Heart Operation Fund, the Social Insurance Institution of
51
Finland, the National Board of Health, the Juho Vainio Foundation, the Yrjo Jahnsson Foundation and the Finnish Foundation for Cardiovascular Research for their most valuable support for the study.
References 1. Kirkendall WM, Feinleib M, Freis ED, Mark AL. AHA committee report. Recommendations for human blood pressure determination by sphygmomanometers. Subcommittee of the AHA postgraduate education committee. Stroke 1981; 12: 5 5 5 A 4 4 A . 2. Dillon MJ. Blood pressure. Arch Dis Child 1988; 63: 347-9. 3. Report of the Second Task Force on Blood Pressure Control in Children 1987. Pediatrics 1987; 79: 1-25, 4. Report of the Task Force on Blood Pressure Control in Children. Pediatrics 1977; 59: 797-820. 5 . Akerblorn HK, Vilkari J, Uhari M, et al. Atherosclerosis precursors in Finnish children and adolescents. I. General description of the cross-sectional study of 1980, and an account of the children's and families' state of health. Acta Paediatr Scand 1985; Suppl 318: 49-63, 6. Dahl M, Uhari M, Vilkari J, et al. Atherosclerosis precursors in Finnish children and adolescents. 111. Blood pressure. Acta Paediatr Scand Suppl 1985; 318: 89102. 7. Evans JG, Prior IAM. Experience with the random-zero sphygmomanometer. Br J Prev SOCMed 1970; 24: 1015. 8. Londe S, Klitzner TS, Moss AJ. Effects of pressure exerted on the stethoscope head on auscultatory blood pressure. In: Loggie JMH, Horan MJ, Gruskin AB, et al., eds. NHLBI Workshop on Juvenile Hypertension: Proceeding from a Symposium, Bethesda, MD, 1983. New York: Biomedical Information Corp., 1984: 10. 9. Uhari M, Nuutinen E, Turtinen J, Study Group of Cardiovascular Risk in Young Finns. Use of random zero sphygmomanometer in a follow-up study of blood pressure in children. Abstract presented at the 2nd International Conference on Preventive Cardiology, Washington D. C., 1989. 10. Uhari M. Evaluation of the measurement of children's blood pressure in an epidemiological multicentre study. Acta Paediatr Scand 1985: Suppl 318: 79-88. 11. Prior IAM, Evans IM. Sodium intake and blood pressure in Pacific populations. Isr J Med Sci 1969; 5 : 608-1 1. 12. Adarns F. Blood pressure of children in the United States. Pediatrics 1978; 61: 931-2. 13. Uhari M, Koskirnles 0. A survey of 164 Finnish children and adolescents with hypertension. Acta Paediatr Scand 1979; 68: 193-8.
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Ann Mnd 73
ISSN: 0785-3890 (Print) 1365-2060 (Online) Journal homepage: http://www.tandfonline.com/loi/iann20
Blood Pressure in Children, Adolescents and Young Adults Matti Uhari, E. Matti Nuutinen, Juha Turtinen, Tytti Pokka, Vesa Kuusela, Hans K. Åkerblom, Matti Dahl, Eero A. Kaprio, Erkki Pesonen, Matti Pietikäinen, Matti K. Salo & Jorma Viikari To cite this article: Matti Uhari, E. Matti Nuutinen, Juha Turtinen, Tytti Pokka, Vesa Kuusela, Hans K. Åkerblom, Matti Dahl, Eero A. Kaprio, Erkki Pesonen, Matti Pietikäinen, Matti K. Salo & Jorma Viikari (1991) Blood Pressure in Children, Adolescents and Young Adults, Annals of Medicine, 23:1, 47-51, DOI: 10.3109/07853899109147930 To link to this article: http://dx.doi.org/10.3109/07853899109147930
Published online: 08 Jul 2009.
Submit your article to this journal
Article views: 16
View related articles
Citing articles: 4 View citing articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=iann20 Download by: [University of Newcastle]
Date: 29 March 2016, At: 21:55
Special Section: Cardiovascular Risk in Young Finns
Blood Pressure in Children, Adolescents and Young Adults
Downloaded by [University of Newcastle] at 21:55 29 March 2016
Matti Uhari’, E. Matti Nuutinenl, Juha Turtinen’, Tytti Pokkal, Vesa Kuusela2, Hans K. Akerblom3, Matti Dah14, Eero A. Kaprio5, Erkki Pesonen5, Matti Pietikainen6, Matti K. Salo7 and Jorma Viikari*
The question of whether blood pressure i s one of the main risk factors for cardiovascular diseases in childhood has been evaluated in a Study of Cardiovascular Risk in Young Finns. In the second follow-up study, carried out in 1986, blood pressure was successfully measured in 2500 individuals aged nine to 24 years using a random zero sphygmomanometer. The mean systolic blood pressure in girls rose from 102 mmHg (95th percentile 119 mmHg) at age nine to 116 mmHg (138 mrnHg) at age 24 and that in boys from 102 mmHg (95th percentile 121 mmHg) to 128 mmHg (148 mmHg). Diastolic blood pressure was more often measurable using Korotkoff’s 5th than the 4th phase. The values observed were similar to those reported by the Second Task Force on Blood Pressure Control in Children, but owing to differences in the methods used to measure blood pressure it cannot be reliably concluded that the blood pressures were similar i n the two series. Even in childhood blood pressure measurement is important, and since it changes with the physical size of the child, observations should be compared with normal values such as those reported here. No data are yet available to suggest that children with blood pressure values in the high normal range would benefit from interventions. Thus normal blood pressure value curves should be applied with caution when assessing children. Key words: blood pressure; normal values. (Annals of Medicine 23: 47-51,
1991)
Introduction The measurement of arterial blood pressure (BP) is an easy method of assessing the condition of the heart and circulatory system. BP is an important predictor of future cardiovascular diseases in adults ( l ) , but whether it has a similar predictive value in childhood remains an open question. Screening for hypertension has been considered unnecessary in childhood (2, 3), and opinions vary on whether to measure the BP of children attending for
From the ’Department of Pediatrics, University of Oulu, Oulu, *Central Statistical Office of Finland, Helsinki, Children’s Hospital, 5First and %econd Department of Pediatrics, University of Helsinki, Helsinki, ‘Department of Pediatrics, University of Turku, 8Department of Medicine, University of Turku. Turku, 6Department of Pediatrics, University of Kuopio, Kuopio, and ‘Department of Pediatrics, University of Tampere, Tampere, Finland. Address and reprint requests: Matti Uhari, M.D., Department of Pediatrics, University of Oulu, SF-90220 Oulu, Finland. 4
regular health visits (2, 3). For clinical purposes it is important to measure BP in sick children and to monitor the child carefully if high values are recorded. Blood pressure in children changes with age and physical size and thus a BP value should be compared with normal curves before deciding on its normality. Normal BP curves are available from the United States of America and from surveys performed in Europe (3, 4). The Second Task Force on Blood Pressure Control in Children pooled the data available from large surveys of normal BP in children, using the first BP measurement to calculate normal curves. Korotkoff’s 4th phase (K4) was used as the marker of diastolic BP under the age of 13 and the 5th phase (K5) from the age of 13 onwards (3). These curves have been criticised for being hard to read and because the switch between the Korotkoff phases according to the age of the child is difficult to accomplish reliably in clinical practice. Children’s BP was one of the main risk factors for cardiovascular diseases measured and monitored in the Study of Cardiovascular Risk in Young Finns. We report here the trends in BP with changes in age, height and weight and compare our values with those
Uhari Nuutinen Turtinen et al.
48
Results and Discussion
Downloaded by [University of Newcastle] at 21:55 29 March 2016
published by the Second Task Force on Blood Pressure in children and young adults.
Systolic BP rose steadily with age in boys and girls (Fig. l), with the rise of diastolic less than that of systolic BP but nevertheless continuous (Fig. 2). The Subjects and Methods systolic BP values were similar to those reported by the The sampling procedure has been described elsewhere Task Force (Fig. 1). To make comparison between the (5). The cross-sectional survey in 1980 involved mea- diastolic BP curves possible it was necessary to use surement of BP in 3012 subjects using a mercury the K4 phase as the marker of diastolic BP in children sphygmomanometer, while three years later only those under 13 and K5 for children over 13 (Fig. 3). The who had participated in 1980 were invited, and BP was diastolic BP when measured using K4 was somewhat measured in 2887 cases. At the second follow-up in higher than the figures published by the Second Task 1986 BP readings were obtained from 2500 individuals. Force, but those measured according to K5 were lower Blood pressure was measured with an ordinary (Fig. 3). This was especially true for the 95 percentile sphygmomanometer on the first two occasions, and curve (Fig. 3). The Task Force on Blood Pressure Control in Chilwith a random zero sphygmomanometer (RZS) in 1986. It was measured after at least three minutes’ rest using dren pooled results of several reports on normal values the right arm, the subjects being seated with their hand for BP in childhood (3),taking the first BP measurement resting on the table. Two cuff sizes, 9.5 x 28 cm and 13 as the final value in the analysis. The measurement of x 40 cm (depending on the size of the subject’s arm), BP is highly vulnerable to many biases, including the were used in order to cover at least two thirds of the terminal digit preference of the observer, and thus upper arm. Readings were taken to the nearest even comparisons between results may be misleading and number of millimeters of mercury and were performed should be performed only if RZS measurements have three times on each subject. Korotkoff’s first phase (KI) been used. The Task Force survey used an ordinary was used as the sign of systolic BP, and both K4 and sphygmomanometer. It has been found that RZS values tend to be lower than those measured with an K5 as indicators of diastolic BP. Each survey employed five measurement groups with ordinary device (7), and thus, although the present BP one nurse in each responsible for BP measurements. curves turned out to be very similar to those published Altogether 11 nurses participated in the three surveys by the Task Force, it is impossible to conclude reliably in 1980 to 1986. The first cross-sectional series of BP from the data available whether the BP in Finnish children and young adults is really similar to the values values has been published elsewhere (6). published by the Second Task Force (3).
SYSTOLIC BP
SYSTOLIC BP GIRLS
150
140
c
BOYS
-
140
130
130
120
120
- -0
. -0
0 -
110
100
-
90
j
I
6
9
12
15
18
---I1 21
k 24
t
AGE, YEARS
Figure 1. Systolic blood pressure mean curve (lower) and 95th percentile curve (upper) in relation to age in girls and boys in the Study of Cardiovascular Risk in Young Finns (I) as compared with the curves published by the Second Task Force (11)(3).
A n n AAnd 9Q
Blood Pressure in Childhood
Downloaded by [University of Newcastle] at 21:55 29 March 2016
90
50
49
I
90
-
The recommendation to use K4 instead of K5 as the indicator of diastolic BP in children under the 13 was based on the assumption that the K5 phase is far too often lacking in children (3). Our results suggest, however, that the K4 phase is absent more often than K5, the latter being missing in 1.1 % of the subjects at most, and that diastolic BP can be measured in all children using the K5 phase (Uhari M, Nuutinen EM, Turtinen J, Pokka T, unpublished observations). The occurrence of a K5 pulse sound depends directly on the pressure applied to the stethoscope head ( 8 ) , and nurses measuring BP in children should be trained to use as little pressure as possible. The rise in BP with increasing age is most probably caused by the growth of the child. Thus the normal curves should be plotted against the height or weight of the child rather than the age. The rise in systolic BP when plotted against height or weight was steeper in boys than in girls (Figs. 4, 5), and there was a drop in the curve when the weight of the child (of either sex) increased above 80 kg. This finding is, however, based on only a few observations (Fig. 5). The Study of Cardiovascular Risk in Young Finns is
Figure 3. Diastolic blood pressure mean curve (lower) and 95th percentile curve (upper) in relation to age in girls and boys in the Study of Cradiovascular Risk in Young Finns (I) as compared with the curves published by the Second Task Force (11)(3). Diastolic blood pressure was measured according to Korotkoffs 4th phase in children under the age of 13 years and Korotkoff's 5th phase in older children.
50
DIASTOLIC EP rnm Hg
GIRLS
5 6
7
8
9 10 11 12 13 14 15 16 17 18 19 2 0 21 22 23 24
DIASTOLIC BP mm Hg
80 90
-
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-
60-
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/#A
__--__--
---
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50/
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8
9 10 11 12 13 14 15 16 17 18 19 2 0 21 22 23 24 AGE. YEARS
50
Uhari Nuutinen Turtinen et al.
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a longitudinal survey in which the same individuals have been followed up since 1980 in three crosssectional series of measurements three years apart. Blood pressure was measured using an ordinary
1
I
1
I
1
1
I
I
I
sphygmomanometer on the first two occasions (6, 9), giving values somewhat lower than those observed in earlier surveys (6, 9) and involving substantial measurement errors caused by the observer on the first
BLOOD PRESSURE
BLOOD PRESSURE mm HQ
GIRLS
BOYS
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130
--
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0 -
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WEIQHT. KG
Figure 5. Mean systolic (--) and diastolic (-) blood pressure curves (lower) and 95th percentile curve (upper) in relation to weight in girls and boys in the Study of Cardiovascular Risk in Young Finns.
Am-
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Blood Pressure in Childhood occasion (10). Thus the observed fall in BP is more probably attributable to the measuring device and measurement errors in the earlier values than to any real fall in BP during the period in question. Hypertension in its early stages is poorly understood, but blood pressure rises with age in childhood. This rise, a consistent finding in the western world (3), has been attributed to the physical growth of the child and thus interpreted as a physiological phenomenon. Nevertheless, there are some primitive cultures in which BP remains at almost the same level throughout life (11). Thus it may be that the rise in BP is actually a part of the early natural history of hypertension (12). Long-term longitudinal surveys of BP starting from childhood would be needed to test this hypothesis. High BP and hypertension are hard to define in childhood. The most commonly used definition is a statistical one which states that all those individuals with BP values above two standard deviations or above the 97.5th percentile, for example, are hypertensive. This means that we accept hypertension as occurring at the same frequency even in neonates, i.e. in about 2.5% of the children. Hypertension in childhood is most often secondary in nature, however, and in these patients their BP is so high that there are hardly any difficulties in defining the sick child as hypertensive (13). Thus normal BP curves should be used cautiously in practice, and no data are presently available to show that children with high normal BP values would benefit from any kind of intervention. It may well be that definitions of hypertension in terms of certain limit values such as 160/90 mmHg are as useful with children as with adults. Although RZS is not usually available in ordinary clinical circumstances, and although it gives somewhat lower BP values than an ordinary mercury sphygmomanometer (7), we suggest that the present normal value curves are more accurate, even for everyday clinical practice, than curves based on ordinary sphygmomanometer measurements. In clinical practice the findings in one individual are being compared to normal curves, and the process is not biased by small deviations in mean values between groups. We thank the Academy of Finland (Medical Research Council, National Research Council for Agriculture and Forestry), the Red Heart Operation Fund, the Social Insurance Institution of
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Finland, the National Board of Health, the Juho Vainio Foundation, the Yrjo Jahnsson Foundation and the Finnish Foundation for Cardiovascular Research for their most valuable support for the study.
References 1. Kirkendall WM, Feinleib M, Freis ED, Mark AL. AHA committee report. Recommendations for human blood pressure determination by sphygmomanometers. Subcommittee of the AHA postgraduate education committee. Stroke 1981; 12: 5 5 5 A 4 4 A . 2. Dillon MJ. Blood pressure. Arch Dis Child 1988; 63: 347-9. 3. Report of the Second Task Force on Blood Pressure Control in Children 1987. Pediatrics 1987; 79: 1-25, 4. Report of the Task Force on Blood Pressure Control in Children. Pediatrics 1977; 59: 797-820. 5 . Akerblorn HK, Vilkari J, Uhari M, et al. Atherosclerosis precursors in Finnish children and adolescents. I. General description of the cross-sectional study of 1980, and an account of the children's and families' state of health. Acta Paediatr Scand 1985; Suppl 318: 49-63, 6. Dahl M, Uhari M, Vilkari J, et al. Atherosclerosis precursors in Finnish children and adolescents. 111. Blood pressure. Acta Paediatr Scand Suppl 1985; 318: 89102. 7. Evans JG, Prior IAM. Experience with the random-zero sphygmomanometer. Br J Prev SOCMed 1970; 24: 1015. 8. Londe S, Klitzner TS, Moss AJ. Effects of pressure exerted on the stethoscope head on auscultatory blood pressure. In: Loggie JMH, Horan MJ, Gruskin AB, et al., eds. NHLBI Workshop on Juvenile Hypertension: Proceeding from a Symposium, Bethesda, MD, 1983. New York: Biomedical Information Corp., 1984: 10. 9. Uhari M, Nuutinen E, Turtinen J, Study Group of Cardiovascular Risk in Young Finns. Use of random zero sphygmomanometer in a follow-up study of blood pressure in children. Abstract presented at the 2nd International Conference on Preventive Cardiology, Washington D. C., 1989. 10. Uhari M. Evaluation of the measurement of children's blood pressure in an epidemiological multicentre study. Acta Paediatr Scand 1985: Suppl 318: 79-88. 11. Prior IAM, Evans IM. Sodium intake and blood pressure in Pacific populations. Isr J Med Sci 1969; 5 : 608-1 1. 12. Adarns F. Blood pressure of children in the United States. Pediatrics 1978; 61: 931-2. 13. Uhari M, Koskirnles 0. A survey of 164 Finnish children and adolescents with hypertension. Acta Paediatr Scand 1979; 68: 193-8.
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