Public Health (1990), 104, 191-194
© The Society of Public Health, 1990
Should School Nurses M e a s u r e Blood Pressure? J. E. Kelsall 1 and A. R. W a t s o n 2
1Child Health Unit, Genera/Hospital, Nottingham/2Paediatric Unit, City Hospital, Nottingham
The inclusion of blood pressure measurements in the routine health appraisal of junior school children was acceptable to children and staff and did not create undue anxiety. Of 677 children only 9 (1:33%) required follow up, 2 being referred to hospital out patients. With appropriate support school nurses should be encouraged to measure blood pressure.
Introduction Hypertension is a significant risk factor for cardio-vascular events in adults ~ and there is evidence that essential hypertension m a y have its origin in childhood. 2 Recent epidemiological research has suggested that regional variations in blood pressure can be identified in the childhood population and correlate with standardised mortality ratios for adult cardiovascular disease? The second report of the Task Force on Blood Pressure Control (1987) from the USA 4 recommended that all children over 3 years of age should have a blood pressure measurement included in the annual physical examination, carried out by the family paediatrician. Mass blood pressure screening in children has not been advocated 5 because it is unlikely to be cost effective in detecting even the rare patients with secondary hypertension. This view has also been put forward in the U K 6 where the suggested model of yearly blood pressure checks is impracticable. However children have regular contact with school nurses who are encouraged to consider health promotion as an important part of their work. This group is well placed to carry out regular blood pressure measurements and we studied the feasibility and problems of including these in their routine health appraisal examinations.
Methods Blood pressure was measured in 10 to l 1-year-old children during the second health appraisal in 18 Junior Schools in Nottingham. The routine health appraisal consists of height and weight measurements, vision testing and a discussion about general health, Parents are not usually present but were informed by letter that their children would have their blood pressure taken, and that this might have to be repeated. This was also explained to the children and teachers by the school nurse. The 10 school nurses received specific training for the study during a half day session. A standard mercury s p h y g m o m a n o m e t e r with the appropriate sized cuff was used with K o r o t k o f f phase I being used to define systolic pressure and K o r o t k o f f IV (muffling) diastolic pressure. Blood pressure recordings were made at the end of each individual health appraisal with the children sitting. Results were plotted on the appropriate blood pressure percentile charts 4 and action carried out according to a previously agreed protocol (Figure 1). Correspondence: J. Kelsall, Child Health Unit, Memorial House, Standard Hill, Nottingham, NGI 6HA.
192
J. E. Kelsall and A. R. Watson
BP 145/100 or higher
Measure B.P. Check percentile
~
' ~ 9Oth percentile
Repeat BP x 2 on separate occasions Check percentile of lowest reading i p>_egrcSthntile~f
Refer to School Clinic Assessment and Health education or referral to out patients
rcentile
< 90th percentile
i 90th-95th e
~ No further action
~dren, height > 90th percentile Measure height and weight I Height < 90th percentile Review B.P. in 6 months Dietary advice if obese Health education
Figure 1 Schoolnurse protocol for BP measurements
Children whose blood pressure after 3 separate measurements was ~>95th percentile were referred to the School Clinic to be seen by the Community Paediatrician after a home visit by the school nurse. Those thought to require further investigation or treatment were referred to a hospital out patient clinic. Results
Blood pressure measurements were recorded from 677 children between September 1987 and February 1988. Eleven children were missed because of poor school attendance, chronic illness or travel abroad. The uptake was therefore 98.4%. Thirty five children (5.2%) had initial blood pressure recordings (systolic and/or diastolic) above the 90th percentile (19 above the 95th percentile). After 2 more readings the blood pressure of 26 of the 35 had fallen to below the 90th percentile. Nine children (1.33%) had blood pressures consistently above the 90th percentile and of these 3 (with pressures between the 90t~95th percentile) were followed up by the school nurse and 6 were referred to the school clinic to be seen by the community paediatrician. Two children, both of whom had a strong family history of hypertension and suffered from epistaxes, were referred to the hospital out-patient department. The nurses found that measuring blood pressure did not add significantly to the time taken for a health appraisal as the measurements were done while they were discussing the child's general health. Few practical problems were encountered and the nurses easily managed the small additional workload, for example home visits and the follow-up of non-attenders.
Should School Nurses Measure Blood Pressure?
193
The school nurses reported great interest from the teachers, many o f whom asked for their own blood pressure to be measured. Few parents and pupils expressed any anxiety and some parents commented that the health appraisal had been more valuable. Discussion
We have shown that it is feasible for appropriately trained school nurses to incorporate blood pressure measurements into their health appraisals. School nurses were already familiar with blood pressure measurement and therefore a relatively small amount of time was needed for training. School nurses felt that the measurement of blood pressure was a recognised nursing procedure and their involvement mirrored the measurement of blood pressure in adults by practice nurses and those in occupational health. The school children and parents were informed beforehand and very little anxiety was generated. The use of an agreed protocol resulted in few referrals to the school clinic or to hospital. The prevalence of significant hypertension in school children is in the order of 1% and it is suggested that children who have readings persistently above the 90th percentile have an increased risk o f developing hypertension in adult life. Our aim was to identify children who may need investigation and possibly treatment, as well as those who require more frequent surveillance than other children. School nurses are able to do this with minimal disruption to the children. Although the school nurses could be considered as screening for hypertension we feel blood pressure measurements in children should be considered as the beginning o f blood pressure surveillance which should continue into and through adult life. The nurses emphasised this in their health education so that children did not think o f a single normal reading as a guarantee that their blood pressure would always remain normal. It is difficult to apply all the criteria for screening to the start of a surveillance programme. However some of the criteria are fulfilled. We aim to identify children who either have a recognised condition, i.e. hypertension or who are in a high risk group. Hypertension has a recognised mortality and morbidity I and both can be reduced with adequate treatment. The measurement itself is well established as a procedure and is acceptable to both adults and children. There is an initial equipment cost but the running costs o f the programme are comparatively small and were met by existing budgets. The nurses easily managed the additional workload within their normal duties and therefore additional staff costs did not arise. It may be considered that the 28 children who had initial blood pressures greater than the 90th percentile, but who had normal readings when recalled were 'false positives'. However there is evidence that these children have an increased risk of labile hypertension in later lifev and it could be argued that they should be identified and have repeat measurements of their blood pressure at future health appraisals. The school nurses perceived blood pressure as a useful health promotion tool and it helped them to reinforce general advice about diet and smoking. They did not feel the small additional workload detracted from other important duties. Home visits to follow up persistent non attenders were also used to discuss the children's general health and the reasons behind the poor attendance. As hypertension is a cardiovascular risk factor and the general public are being encouraged to have their blood pressure taken regularly it would seem sensible to measure this physiological parameter in childhood. School nurses are ideally placed to do this and could bridge the gap between the often infrequent measurement o f blood pressure in sick children in the U K and the recommendations of the Task Force.
194
J. E. Kelsall and A. R. Watson
Acknowledgements We would like to thank all the school nurses who participated in the study and Rachel Horn for typing the manuscript.
References 1. Truett, J., Cornfield, J. & Kannel, W. (1967). A multivariate analysis of the risk of coronary heart disease in Framingham. Journal of Chronic Disease, 20, 511-524. 2. Lauer, R.M., Clarke, W . R . & Beaglehole, R. (1984). Level, trend and variability of blood pressure during childhood: The Muscatine Study. Circulation, 69, 242-249. 3. Whincup, P.H., Shaper, A . G . , Cook, D . G . , Macfarlane, D.J. & Walker, M. (1988). Blood Pressure in British Children: Associations with Adult Blood Pressure and Cardiovascular Mortality. Lancet, 2, 890-893. 4. Report of the Second Task Force on Blood Pressure Control in Children. (1987). Pediatrics, 79, 125. 5. Fixler, D.E. & Laird, W.P. (1983). Validity of mass blood pressure screening in children. Pediatrics, 72, 459-463. 6. Dillon, M.J. (1988). Blood pressure. Archives of Diseases in Childhood, 63, 347-349. 7. Visser, M. C., Grobbee, D. E. & Hofman, A. (1987). Determinants of rise in blood pressure in normotensive children. Journal of Hypertension, 5, 36%370.
© The Society of Public Health, 1990
Should School Nurses M e a s u r e Blood Pressure? J. E. Kelsall 1 and A. R. W a t s o n 2
1Child Health Unit, Genera/Hospital, Nottingham/2Paediatric Unit, City Hospital, Nottingham
The inclusion of blood pressure measurements in the routine health appraisal of junior school children was acceptable to children and staff and did not create undue anxiety. Of 677 children only 9 (1:33%) required follow up, 2 being referred to hospital out patients. With appropriate support school nurses should be encouraged to measure blood pressure.
Introduction Hypertension is a significant risk factor for cardio-vascular events in adults ~ and there is evidence that essential hypertension m a y have its origin in childhood. 2 Recent epidemiological research has suggested that regional variations in blood pressure can be identified in the childhood population and correlate with standardised mortality ratios for adult cardiovascular disease? The second report of the Task Force on Blood Pressure Control (1987) from the USA 4 recommended that all children over 3 years of age should have a blood pressure measurement included in the annual physical examination, carried out by the family paediatrician. Mass blood pressure screening in children has not been advocated 5 because it is unlikely to be cost effective in detecting even the rare patients with secondary hypertension. This view has also been put forward in the U K 6 where the suggested model of yearly blood pressure checks is impracticable. However children have regular contact with school nurses who are encouraged to consider health promotion as an important part of their work. This group is well placed to carry out regular blood pressure measurements and we studied the feasibility and problems of including these in their routine health appraisal examinations.
Methods Blood pressure was measured in 10 to l 1-year-old children during the second health appraisal in 18 Junior Schools in Nottingham. The routine health appraisal consists of height and weight measurements, vision testing and a discussion about general health, Parents are not usually present but were informed by letter that their children would have their blood pressure taken, and that this might have to be repeated. This was also explained to the children and teachers by the school nurse. The 10 school nurses received specific training for the study during a half day session. A standard mercury s p h y g m o m a n o m e t e r with the appropriate sized cuff was used with K o r o t k o f f phase I being used to define systolic pressure and K o r o t k o f f IV (muffling) diastolic pressure. Blood pressure recordings were made at the end of each individual health appraisal with the children sitting. Results were plotted on the appropriate blood pressure percentile charts 4 and action carried out according to a previously agreed protocol (Figure 1). Correspondence: J. Kelsall, Child Health Unit, Memorial House, Standard Hill, Nottingham, NGI 6HA.
192
J. E. Kelsall and A. R. Watson
BP 145/100 or higher
Measure B.P. Check percentile
~
' ~ 9Oth percentile
Repeat BP x 2 on separate occasions Check percentile of lowest reading i p>_egrcSthntile~f
Refer to School Clinic Assessment and Health education or referral to out patients
rcentile
< 90th percentile
i 90th-95th e
~ No further action
~dren, height > 90th percentile Measure height and weight I Height < 90th percentile Review B.P. in 6 months Dietary advice if obese Health education
Figure 1 Schoolnurse protocol for BP measurements
Children whose blood pressure after 3 separate measurements was ~>95th percentile were referred to the School Clinic to be seen by the Community Paediatrician after a home visit by the school nurse. Those thought to require further investigation or treatment were referred to a hospital out patient clinic. Results
Blood pressure measurements were recorded from 677 children between September 1987 and February 1988. Eleven children were missed because of poor school attendance, chronic illness or travel abroad. The uptake was therefore 98.4%. Thirty five children (5.2%) had initial blood pressure recordings (systolic and/or diastolic) above the 90th percentile (19 above the 95th percentile). After 2 more readings the blood pressure of 26 of the 35 had fallen to below the 90th percentile. Nine children (1.33%) had blood pressures consistently above the 90th percentile and of these 3 (with pressures between the 90t~95th percentile) were followed up by the school nurse and 6 were referred to the school clinic to be seen by the community paediatrician. Two children, both of whom had a strong family history of hypertension and suffered from epistaxes, were referred to the hospital out-patient department. The nurses found that measuring blood pressure did not add significantly to the time taken for a health appraisal as the measurements were done while they were discussing the child's general health. Few practical problems were encountered and the nurses easily managed the small additional workload, for example home visits and the follow-up of non-attenders.
Should School Nurses Measure Blood Pressure?
193
The school nurses reported great interest from the teachers, many o f whom asked for their own blood pressure to be measured. Few parents and pupils expressed any anxiety and some parents commented that the health appraisal had been more valuable. Discussion
We have shown that it is feasible for appropriately trained school nurses to incorporate blood pressure measurements into their health appraisals. School nurses were already familiar with blood pressure measurement and therefore a relatively small amount of time was needed for training. School nurses felt that the measurement of blood pressure was a recognised nursing procedure and their involvement mirrored the measurement of blood pressure in adults by practice nurses and those in occupational health. The school children and parents were informed beforehand and very little anxiety was generated. The use of an agreed protocol resulted in few referrals to the school clinic or to hospital. The prevalence of significant hypertension in school children is in the order of 1% and it is suggested that children who have readings persistently above the 90th percentile have an increased risk o f developing hypertension in adult life. Our aim was to identify children who may need investigation and possibly treatment, as well as those who require more frequent surveillance than other children. School nurses are able to do this with minimal disruption to the children. Although the school nurses could be considered as screening for hypertension we feel blood pressure measurements in children should be considered as the beginning o f blood pressure surveillance which should continue into and through adult life. The nurses emphasised this in their health education so that children did not think o f a single normal reading as a guarantee that their blood pressure would always remain normal. It is difficult to apply all the criteria for screening to the start of a surveillance programme. However some of the criteria are fulfilled. We aim to identify children who either have a recognised condition, i.e. hypertension or who are in a high risk group. Hypertension has a recognised mortality and morbidity I and both can be reduced with adequate treatment. The measurement itself is well established as a procedure and is acceptable to both adults and children. There is an initial equipment cost but the running costs o f the programme are comparatively small and were met by existing budgets. The nurses easily managed the additional workload within their normal duties and therefore additional staff costs did not arise. It may be considered that the 28 children who had initial blood pressures greater than the 90th percentile, but who had normal readings when recalled were 'false positives'. However there is evidence that these children have an increased risk of labile hypertension in later lifev and it could be argued that they should be identified and have repeat measurements of their blood pressure at future health appraisals. The school nurses perceived blood pressure as a useful health promotion tool and it helped them to reinforce general advice about diet and smoking. They did not feel the small additional workload detracted from other important duties. Home visits to follow up persistent non attenders were also used to discuss the children's general health and the reasons behind the poor attendance. As hypertension is a cardiovascular risk factor and the general public are being encouraged to have their blood pressure taken regularly it would seem sensible to measure this physiological parameter in childhood. School nurses are ideally placed to do this and could bridge the gap between the often infrequent measurement o f blood pressure in sick children in the U K and the recommendations of the Task Force.
194
J. E. Kelsall and A. R. Watson
Acknowledgements We would like to thank all the school nurses who participated in the study and Rachel Horn for typing the manuscript.
References 1. Truett, J., Cornfield, J. & Kannel, W. (1967). A multivariate analysis of the risk of coronary heart disease in Framingham. Journal of Chronic Disease, 20, 511-524. 2. Lauer, R.M., Clarke, W . R . & Beaglehole, R. (1984). Level, trend and variability of blood pressure during childhood: The Muscatine Study. Circulation, 69, 242-249. 3. Whincup, P.H., Shaper, A . G . , Cook, D . G . , Macfarlane, D.J. & Walker, M. (1988). Blood Pressure in British Children: Associations with Adult Blood Pressure and Cardiovascular Mortality. Lancet, 2, 890-893. 4. Report of the Second Task Force on Blood Pressure Control in Children. (1987). Pediatrics, 79, 125. 5. Fixler, D.E. & Laird, W.P. (1983). Validity of mass blood pressure screening in children. Pediatrics, 72, 459-463. 6. Dillon, M.J. (1988). Blood pressure. Archives of Diseases in Childhood, 63, 347-349. 7. Visser, M. C., Grobbee, D. E. & Hofman, A. (1987). Determinants of rise in blood pressure in normotensive children. Journal of Hypertension, 5, 36%370.
