BLOOD PRESSURE MEASUREMENT TECHNIQUE IN CHILDREN
Blood pressure should be measured by mercury sphygomanometers, while aneroid
sphygmomanometers requires to be calibrated periodically. Automatic osilometric is a good
blood pressure measurement instrument for infant and children, because auscultation
technique at rest time is difficult to measure in this age group. However, this instrument is
quite expensive, needs maintenance, and should be calibrated periodically.
The lenght of the cuff bladder should cover at least 80% of the upper arm
circumference, and the width of the cuff bladder at least 40 - 75% of upper arm
circumference (at a point midway between the olecranon and acromion, see figure 1). An
oversized cuff can underestimate the blood pressure, whereas an undersized cuff can
overestimate the measurement.
Figure 1 Upper arm circumference should be measured midway between the olecranon and
acromial process
Adapted from Gulati
Blood pressure should be measured in a controlled environment after five minutes of
rest in the seated position with the right arm supported at heart level. If the blood pressure
is greater than 90th percentile, the blood pressure should be repeated twice at the same
office visit to test the validity of the reading.
Ambulatory blood pressure monitoring (APBM) requires a patient to wear a portable
monitor that records blood pressure over a spesific period. APBM usually used in
hipertension episodic, chronic kidney failure, hesitant hipertension in adolescent, and in
determining the suspicion of organ target injury due to hipertension. Sistolic blood pressure
is determined at the time when first Korotkoff sound heard. Diastolic blood pressure is
actually heard when the sound insignificant to disappear. Palpation technique is used to
measure blood pressure quickly. However, this technique usually reveal 10 mmHg lower
than auscultation technique.
Limitation
Based on The Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood
Pressure in Children and Adolescent :
- Hypertension is a sistolic blood pressure and diastolic blood pressure greater than or
equal to 95th percentile based on sex, age, and height in three times or more
measurement.
- Prehypertension is a sistolic blood pressure and diastolic blood pressure greater than or
equal to 90th percentile but less than 95th percentile. Look for any risk factor such as
obesity. Researches shows that this group has a greater possibility to develop
hypertension in adult compared to those in normotension children.
- Blood pressure levels greater than or equal to 120/80 mmHg for adolescent must be
considered as prehypertension.
- Children with blood pressure measurement levels greater to 95th percentile in a medical
setting, but normal outside the medical setting called as white coat hypertension. This
group has a better prognosis to develop hypertension or cardiovascular disease in later
life compared to those with sustain hypertension.
- Emergency hypertension is a severe hypertension with life threatening complication
such as encephalopathy (stroke, seizure, focal defisit), acute myocard infark, pulmonary
oedema, aneurisma aorta, or acute kidney failure.
Table 1 shows hypertension classification for children above 1 year of age and adolescent.
Blood pressure based on age, sex, and height shows in appendix 1, 2 and 3.
Table 1 Hypertension classification in children ≥ 1 year of age and adolescent
Classification
Normal blood pressure
Prehypertension
Hypertension
Stage 1 hypertension
Stage 2 hypertension
Limitation
Systolic and dyastolic blood pressure less than
90th percentile
Systolic or dyastolic blood pressure greater
than or equal to 90th percentile but less than
95th percentile
Systolic or dyastolic blood pressure greater
than or equal to 95th percentile plus 5mmHg
Systolic or dyastolic blood pressure from 95th
percentile to 99th percentile plus 5 mmHg
Systolic or dyastolic blood pressure greater
than 99th percentile plus 5 mmHg
Evaluation
After hypertension been diagnosed, than requires careful anamnesis and physical
examination to detect underlying causes and target organ injury. Accurate information by
anamnesis and physical examination could avoid evpensive and unecessary laboratory and
radiology examination.
The evaluation of any hypertension evidence based on age, the degree of hypertension,
any organ target injury, and risk factors individually.
Appendix 1
Blood pressure levels for boys by age and height percentile
Adapted from The fourth report on the diagnosis, evaluation, and treatment of high blood pressure
in children and adolescent
Appendix 2
Blood pressure levels for girls by height and age percentile
Adapted from The fourth report on the diagnosis, evaluation, and treatment of high blood pressure
in children and adolescent
LEARNING GUIDE FOR BLOOD PRESSURE MEASUREMENT
BY AUSCULTATION TECHNIQUE
STEPS
NO.
I. Preparation
A.
B.
C.
Instrument :
1. Fitting the size of the cuff bladder to the children
2. Choosing the appropriate cuff bladder based on the lenght and
the width. The width of the cuff bladder should cover at least
40% - 75% of upper arm circumference at the point midway
between the olecranon and acromion. The lenght of the cuff
bladder should cover 80-100% of upper arm circumference.
3. Checking the manometers for any mechanic defects that will
influenced the measurement:
 Check for bubble in mercury gauge
 Turn on the mercury gauge
 Flow the cuff
PLACE :
In a controlled situation
PATIENT :
1. Not consuming any stimulant drugs or foods
2. Sitting for 5 minutes in a chair with assistance, the leg hang up,
and right arm support in a position with the right arm supported
at heart level. In younger children, measurement done in a lie
down position with arm side straight to the body.
II. Blood Pressure Measurement
1.
2.
3
4.
Covering upper arm with cuff bladder strongly ± 3 cm from
elbow/cubiti fossa as under limit.
Determining brachialis arteri position by palpating cubiti fossa
then put the stethoscope on it.
Pump up the cuff for about 20-30 mmHg above the pressure
needs to make occlusion in brachialis artery. Blood pressure the
slowly decrease 2-3 mmHg/ secon until korotkoff sound is heard
(phase 1 korotkoff = systolic blood pressure), then heard phase-2,
phase 3, phase-4 and phase-5. The disappearance of the sound
(phase-5) is indicated dyastolic blood pressure (the sound heard
quietly), used as a marker of dyastolic blood pressure.
After you got the result, map the blood pressure based on
Percentile of Height of the children. Determine the diagnosis of
the child, is it Normal or Hypertension stage 1 or Hypertension
stage 2
SCORE LEVEL
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