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Evidence-based practice: noninvasive blood pressure measurement in children.

Blood pressure (BP) reflects one's cardiovascular status. BP alterations may indicate particular diseases, response to illness, and outcomes of treatment. According to a National Heart, Lung, and Blood-sponsored study, systolic and diastolic BPs have risen substantially in children and teens between 1988 and 2000 (Muntner, He, Cutler, Wildman, & Whelton, 2004). In children, hypertension is most often associated with coarctation of the aorta or renal disease; more recently, it is linked to obesity (National High Blood Pressure Education Program Working Group, 2004; Sorof & Daniels, 2002). For premature neonates, rapid recognition of hypotension is crucial in preventing cerebral complications (Stebor, 2005). For these reasons, BP measurement is a skill frequently performed by nurses and other health care workers in a variety of pediatric settings.

Nurses and other health care providers initially learn BP measurement techniques from classroom instruction, videos/CD-ROMs, and laboratory practice, often with double-headed stethoscopes so that instructors can validate proper techniques and readings. However, knowledge of the many steps of BP measurement and quality of this important skill may deteriorate over time (Ahmed, 1997; Armstrong, 2002; Pickering et al., 2005; Tholl, Forstner, & Anlauf, 2004). Inaccurate BP measurement may lead to an incorrect diagnosis and/or unnecessary follow-up and treatment (Armstrong, 2002; Jones, Appel, Sheps, Roccella, & Lenfant, 2003; Menard & Park, 1995; Pickering et al., 2005).

Validation of BP measurement techniques and devices has been recommended by experts in both Europe and the United States (Jones et al., 2003; O'Brien, Waeber, Parati, Staessen, & Myers, 2001; Pickering et al., 2005; Tholl et al., 2004). Furthermore, the Subcommittee of Professional and Public Education of the American Heart Association Council on High Blood Pressure Research strongly recommends retraining of all health professionals (Pickering et al., 2005).

Indications for Blood Pressure Measurement in Children

Pediatric experts recommend that blood pressures (BPs) be measured annually in children greater than 3 years of age through adolescence when seen in medical settings (National High Blood Pressure Education Program Working Group, 2004). Comparison of BPs in upper and lower extremities should be obtained at least once to detect abnormalities, such as coarctation of the aorta in which the lower extremity BP would be less than in the upper extremity. BPs should also be taken at least once during every health care episode. For children less than 3 years of age, BP should be obtained in special circumstances such as when children are of very low birthweight, or if they have other neonatal complications, congenital heart disease, suspected or known renal disease, solid organ or bone marrow transplant, malignancy, elevated intracranial pressure, and/or are treated with drugs known to increase BP (National High Blood Pressure Education Program Working Group, 2004).

The 4th Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents (National High Blood Pressure Education Program Working Group, 2004) noted that blood pressure standards based on gender, age and height are the most precise. The latest BP tables with the normal ranges of BPs are readily accessible (refer to internet address for this report in the reference list) and include the 50th, 90th, 95th, and 99th percentiles of systolic BP (SBP) and diastolic BP (DBP) for girls and boys. Systolic blood pressure is used to diagnose hypertension in children less than a year old. According to the report, "hypertension is defined as average SBP and/or DBP that is [greater than or equal to] 95th percentile for gender, age, and height on [greater than or equal to] 3 occasions" (p. 556).

Factors Influencing BP Accuracy

Patient preparation. Certain steps should be taken to prepare a child for BP measurement. Children should not have stimulant foods or medications prior to BP measurement. BPs should be obtained in a quiet, non-anxiety producing environment. Resting for at least 3 to 5 minutes before taking the BP is recommended (Pickering et al., 2005). Consider the influence of a full bladder if trying to encourage a child to sit still for any length of time. If possible, avoid taking the BP before invasive procedures when anxiety and fear may be highest (Menard & Park, 1995; National High Blood Pressure Education Program Working Group, 2004). Anxiety may be reduced by allowing the child to sit on a parent's lap. Also a simple explanation of the procedure, particularly how the cuff will feel, e.g. tightening, hugging the arm, is necessary (Hockenberry, Wilson, Winkelstein, & Kline, 2003).

Similar to adults, some children exhibit the "white coat" effect. Anxiety during the measurement performed by a physician, nurse, or other health care provider produces a temporary increase in BP values. Therefore, one high reading is not sufficient for a diagnosis of hypertension. This diagnosis must be based on the average of many BP measurements over weeks and months (National High Blood Pressure Education Program Working Group, 2004).

Most experts recommend measuring BPs on the bare arm. However, several studies have demonstrated that a thin layer of soft padding or clothing did not significantly affect auscultatory or oscillometric BP measurements in normotensive adults (Archer & Smith, 2001; Kahan, Yaphe, Knaani-Levinz, & Weingarten, 2003; Liebl, Holzgreve, Schulz, Crispin, & Bogner, 2004). However, in some hypertensive patients, although group mean differences remained small, the range of differences for individuals was clinically significant (Kahan et al., 2003). Further research in the pediatric population is needed.

Monitoring devices. Auscultation is the preferred measurement technique because normal values found in blood pressure tables are based on this method (National High Blood Pressure Education Program Working Group, 2004). Mercury sphygmomanometry readings are considered the "gold standard" and, unlike other devices, do not have to be calibrated. Because mercury is a known environmental toxin, there is a movement to eliminate mercury sphygmomanometers in hospitals and other health care settings (Health Care Without Harm, 2002). Aneroid sphygmomanometers are the substitution but studies are inconsistent about their accuracy (Canzanello, Jensen, & Schwartz, 2001; Jones, Frohlich, Grim, Grim, & Taubert, 2001; Tholl et al., 2004). Rough handling and dropping have been implicated as causes of imprecision. Therefore, the device should be calibrated biannually (National High Blood Pressure Education Program Working Group, 2004; Pickering et al., 2005). Hybrid sphygmomanometers are in development and combine auscultation of Korotkoff sounds by stethoscope with displays that are either simulated mercury columns, or simulated digital or aneroid displays (Graves, Tibor, Murtagh, Klein, & Sheps, 2004). However, these devices have not been tested in children.

The oscillometric technique of BP measurement has gained popularity over the last 20 years. Common examples of this type of automatic BP monitor are the Dinamap[R] and the Welch Allyn Spot Vital Signs. In pediatrics, it is recommended in situations where frequent BP readings are necessary, e.g. intensive care, and in newborns and young infants in whom auscultation can be challenging (Dobbins, 2002; National High Blood Pressure Education Program Working Group, 2004; Stebor, 2005). Oscillometric devices detect changes in amplitude of arterial wall pulsations. The point of maximal oscillation corresponds to the mean arterial pressure. Systolic and diastolic pressures are determined indirectly according to derived algorithms (Pickering et al., 2005). A major concern voiced by experts is that each manufacturer has it own algorithms for each device, making readings from one device potentially different from another device. Nonetheless, the convenience and ease of its use has made it one of the most common methods of measurement in the acute care setting.

Oscillometric BP measurements eliminate many of the potential problems of auscultation, including deflation of the cuff too quickly, inability to hear soft Korotkoff sounds, rounding of numbers, and observer bias (National High Blood Pressure Education Program Working Group, 2004). However, experts recommend that if the BP is elevated, exceeding the 90th percentile, the measurement should be repeated by the auscultatory method (National High Blood Pressure Education Program Working Group, 2004; Pickering et al., 2005). Artifact from patient-caused (e.g. crying, struggling, seizures) or clinician-caused (e.g. moving the bed, leaning on cuff or tubing) motion are potential sources of inaccuracy (Stebor, 2005). Many oscillometric device manufacturers prohibit use of the devices in patients with irregular heart rates because of the difficulty in detecting pulse amplitude to derive pressures.

Numerous studies of the accuracy of oscillometric techniques exist. Overall, these devices are considered an acceptable alternative compared to the sphygmomanometer in children (Pickering et al., 2005), including those with diabetes, and cardiovascular and renal disorders (Jin, Donaghue, Fairchild, Chan, & Silink, 2001; Mattu, Heran, & Wright, 2004). However, in a study of 7,280 school children ages 5 through 17 years, Park, Menard, and Yuan (2001) found oscillometric DBPs and SBPs were 5 and 10 mmHg higher, respectively, than auscultatory DBPs and SBPs. Park et al. (2001) suggested cautious use of these devices when diagnosing children with hypertension. Similarly, Barker, Shiell, and Law (2000) advised that in clinical situations where "absolute" values are needed to guide care, some oscillometric devices are not accurate. Stebor (2005) reviewed literature on comparisons of intra-arterial devices with oscillometric devices in neonates and infants and found conflicting results. Stebor proposes that some of these discrepancies may have been due to different data collection procedures, types of devices, wrong-sized cuffs, and inclusion of hypotensive individuals.

Ambulatory BP monitoring (ABPM) has also become more prevalent in the diagnosis and treatment of hypertension in children. These devices measure continuous BPs for 24 hours or longer and compute a mean BP. They can minimize "white coat" effects (National High Blood Pressure Education Program Working Group, 2004; Sorof & Portman, 2001). Experts in the field of pediatric hypertension typically use these devices rather than nurses in community or hospital settings.

Devices for BP measurement in the wrist and the finger have been developed. Only one study was found comparing oscillometric and auscultatory readings at the wrist in children and adolescents (Bald, Westhues, & Bonzel, 1996). Two wrist devices were evaluated and produced different results. The researchers recommended further testing of device reliability in children. Pickering et al. (2005) claim that finger BP devices are costly, inconvenient, and relatively inaccurate and, therefore, do not recommend these devices for routine practice.

Site of BP measurement. The arm is the site of choice for BP measurement. The right arm is preferred for BP measurement in children for two reasons. First, standardized BP tables reflect right arm readings. Second, clinicians may get false low readings in the left arm if children have coarctation of the aorta (National High Blood Pressure Education Program Working Group, 2004). The cuff is positioned over the palpated brachial artery with its lower edge 2 to 3 centimeters above the antecubital fossa (National High Blood Pressure Education Program Working Group, 2004; Pickering et al., 2005).

Taking blood pressures on an arm with compromised peripheral circulation, intra-arterial catheters, intravenous catheters, arteriovenous fistulas, and peripherally inserted central catheters (PICC) should be avoided (Intravenous Nurses Society, 2000). Frequent oscillometric BP measurements can affect continuous pulse oximetry readings if on the same limb (Giuliano, 2006; Stebor, 2005).

In some settings, there has been an increase in the use of forearm BP measurements when the available cuff does not fit or the upper arm is inaccessible. For forearm BPs, the cuff is positioned midway between the wrist and the antecubital fossa. If auscultation is used, the stethoscope is placed over the radial artery. Studies comparing forearm to upper arm oscillometric BPs have been conducted, but only 2 studies were found in which children were included as subjects (Schell et al., 2005; Singer, Kahn, Thode, & Hollander, 1999). Because of lack of specific information about these subjects and their few numbers, findings from these studies cannot be generalized to children. However, there is statistically significant evidence that forearm BP is not interchangeable with upper arm BP in obese patients (Pierin, Alavarce, Gusmao, Halpern, & Mion, 2004), seated adult emergency department patients (Schell et al., 2005), and adult medical-surgical patients in seated or head of bed (HOB) elevated 45 degree positions (Schell et al., 2006). Forearm BPs are noted to be higher than the upper arm and these differences are more pronounced when the HOB is elevated. Studies in the pediatric population may be warranted; however, the author queried several experts in a major pediatric hospital and found that the calf site, not the forearm, is more commonly used if the upper arm is not available.

Calf blood pressures are measured with the cuff placed approximately 2.5 centimeters above the medial malleoli. If auscultation is used, the stethoscope can be placed either over the dorsalis pedis or posterior tibial artery (Hockenberry et al., 2003). Comparisons of arm versus calf BPs in children, using the same-sized cuff, produced varied results. Frauman, Lansing and Fennel (1984) found large differences in systolic but not diastolic auscultatory BPs in 375 pairs of measures from 4 male hemodialysis patients. Investigating oscillometric differences between the two sites in 219 full-term newborns, Park and Lee (1989) concluded that calf and arm BPs were almost identical. Although Axton, Smith, Bertrand, Dy and Liehr (1995) found no significant differences between mean systolic and diastolic BP readings of 56 hospitalized infants, they established through analysis of individual subject data, that large clinical differences (> 10 mmHg) existed for 66% of the sample. Kunk and McCain (1996) compared arm BPs with calf BPs in 65 preterm infants, and interestingly, no significant differences were found during the first 5 days of life. However, after that time, arm BPs were more accurate. Finally, a study with children between ages of 2 weeks and 3 years in a pediatric outpatient unit yielded wide variation in BP measurements and the researchers concluded that calf and arm BPs were not interchangeable (Crapanzano et al., 1996). Crossland, Furness, Abu-Harb, Sadagopan, and Wren (2004) came to a similar conclusion in their investigation of variability of four limb BPs in normal neonates. The majority of studies included children less than 6 years of age and researchers used various procedures for data collection and analyses. Further investigations are needed to clarify the accuracy of calf BPs in pediatrics.

The thigh is the least preferred for BP measurement. The cuff is applied just above the knee and, if auscultating, the stethoscope is placed over the popliteal artery (Hockenberry et al., 2003). Positioning the patient supine is suggested. According to Pickering et al. (2005), thigh BP measurement is often used when coarctation of the aorta is suspected. Hockenberry et al. (2003) state that oscillometric thigh BPs are the most uncomfortable for children. Interestingly, in the research-based American Association of Critical Care Nurses' Protocols for Practice (Giuliano, 2006), the thigh is not a recommended site.

Body and arm position. For standard assessment of blood pressure, children should be seated, with their back supported, and their feet resting on the floor. Crossed legs at the knee can be a potential source of error when measuring BP. Physiologically, blood volume from the dependent vascular beds moves to the thoracic compartment (Foster-Fitzpatrick, Ortiz, Sibilano, Marcantonio, & Braun, 1999). Systolic and diastolic BPs, measured by both oscillometry and auscultation, increased significantly in adult hypertensive patients (Foster-Fitzpatrick et al., 1999; Pinar, Sabuncu, & Oksay, 2004) and in a well-senior population (Keele-Smith & Price-Daniel, 2001). Studies in pediatrics were not found.

The antecubital fossa should be positioned at heart level. Heart level is considered mid-sternum, 4th intercostal space, the approximate location of the right atrium (National High Blood Pressure Education Program Working Group, 2004; Pickering et al., 2005). Despite this description, health care providers vary in their placement of patients' arms. For a patient in the supine position, Terent and Breig-Asberg (1994) used a small pillow to raise the arm while Netea, Elving, Lutterman, and Thien (2002) positioned the patient's arm next to the body, resting on the bed. The influences of body and arm positions should be considered interdependent (Netea, Lenders, Smits, & Thien, 2003).

It is important to note that published studies on the effects of arm and body position on BP measurements have focused on adults (Mourad et al., 2003; National High Blood Pressure Education Program Working Group, 2004; Netea et al., 2002; Netea, Lenders, & Thien, 1999; Netea, et al., 2003; Pickering et al., 2005; Terent & Breig-Asberg, 1994). Significant findings on the influence of arm position include: (a) increases in systolic and diastolic BPs comparing seated patients with arms on chair arm-rests or dependent versus arms supported at mid-sternum (Mourad et al., 2003; Netea et al., 1999; Netea et al., 2002; Terent & Breig-Asber, 1994); and (b) underestimation of the prevalence of orthostatic hypotension when the arm is incorrectly positioned at the patient's side while standing (Netea et al., 2002). Studies on body position demonstrated that systolic and diastolic BPs were significantly lower in seated patients than supine patients when the arm was positioned at heart level (Netea et al., 2002; Terent & Breig-Asber, 1994). Further study is needed, particularly in the pediatric population.

Cuff size. Selection of the proper-sized cuff is considered one of the most important factors when measuring BP (Arafat & Mattoo, 1999; National High Blood Pressure Education Program Working Group, 2004). Cuff size refers to the inner inflatable bladder (Hockenberry et al., 2003). In a study of 1582 children ages 10 to 17 years, smaller cuffs than required resulted in significantly higher readings while larger cuffs than required gave significantly lower readings (Gomez-Marin, Prineas, & Rastam, 1992). The National High Blood Pressure Education Program Working Group on High Blood Pressure (2004) reported that the degree of overestimation with a small cuff was greater than the degree of underestimation with a large cuff. Despite labeling of BP cuffs with terminology such as infant, child, small adult, etc., sizes may actually differ from one manufacturer to another (Arafat & Mattoo, 1999; National High Blood Pressure Education Program Working Group, 2004).

For appropriate fit, the width of the inflatable bladder of BP cuffs should be at least 40% of the arm circumference at a point midway between the olecranon and the acromion. The bladder length should cover 80% to 100% of the arm circumference. Therefore, the bladder width-to-length ratio should be at least 1:2. Not all manufactured cuffs meet this criterion (National High Blood Pressure Education Program Working Group, 2004). If the cuff is too small, the next largest size should be selected. Also, if the measured arm circumference falls within two of the manufacturer's cuff sizes, the larger cuff should be used. The National High Blood Pressure Education Program Working Group on High Blood Pressure in Adolescents and Children (2004) recommended adoption of standard-sized cuffs with specific widths and lengths based on age and arm circumference for all pediatric BP devices.

Cuff application. Prior to obtaining auscultatory BPs, the nurse should locate the artery (brachial, radial, dorsalis pedis, or posterior tibial depending on site chosen) by palpation. After squeezing air from the cuff, the cuff should be wrapped smoothly and snugly around the limb, but not too tight that it will cause venous congestion. The cuff should be applied so that the middle of the bladder, typically indicated by the manufacturer's marker, is located over the appropriate artery (Stebor, 2005; Hockenberry et al., 2003).

Auscultatory procedure. A pediatric stethoscope is recommended for BP measurement in small children and infants. Listening with the bell of the stethoscope may allow the nurse to hear the softer Korotkoff sounds of these children more easily. Too much pressure applied with the stethoscope may affect the quality of Korotkoff's sounds (Hockenberry et al., 2003). A high-quality stethoscope with short tubing can also promote accurate measurement. For arm BPs, the stethoscope is placed proximal and medial to the antecubital fossa (National High Blood Pressure Education Program Working Group, 2004; Pickering et al., 2005). For other limb sites, the stethoscope is placed over the designated artery.

Initially, the nurse should obtain a palpated systolic pressure. The nurse locates the pulse at the designated artery and then inflates the cuff until the pulse is occluded. This pressure value is noted. After waiting at least 1-2 minutes, the nurse inflates the cuff 30 mmHg above this palpated pressure in order to obtain the most accurate systolic pressure and to avoid the potential of an auscultatory gap (National High Blood Pressure Education Program Working Group, 2004; Pickering et al., 2005).

The first Korotkoff sound corresponds to the onset of clear tapping. The initial tapping is considered the systolic BP. The fifth Korotkoff sound corresponds to diastolic BP and is considered the disappearance of any sounds. In some children, the sound remains to 0 mmHg. In this situation, the fourth Korotkoff sound, indicated by muffling of sound, is considered the diastolic BP (National High Blood Pressure Education Program Working Group, 2004; Pickering et al., 2005). There may be a several mm Hg difference between the fourth and fifth Korotkoff sounds, particularly in preadolescent boys (Sinaiko, Gomez-Marin, & Prineas, 1990). The importance of a quiet environment with few distractions is evident. When sounds are inaudible or faint, systolic BP by palpation or Doppler may be necessary (Pickering et al., 2005). In these cases, obtaining the average of two measurements is recommended.

For accuracy, the nurse needs to read the mercury column at eye level. Deflate the bladder at 2 to 3 mm/sec while listening for Korotkoff sounds. The values should not be rounded but recorded to the nearest 2 millimeter (Picketing et al., 2005).

Oscillometric procedure. The preliminary steps of the automatic oscillometric and auscultatory BP procedures are very similar. Appropriate preparation of the patient, positioning of the body and arm, selection and application of the cuff are required as detailed in the previous sections. Manufacturers of oscillometric devices typically provide a chart of arm circumferences and corresponding cuff sizes. After placing the appropriately sized cuff, the nurse connects it to the BP monitor. Tubing should be free of kinks. The nurse selects the correct patient mode (adult, pediatric, or neonate) if this is an option on the device. Many of these devices can be programmed to measure at certain intervals. Stabilization of the limb is important because movement causes artifact (Stebor, 2005).


It is important for pediatric nurses to maintain current knowledge on BP measurement through review of recent research, scientific statements, and other literature. Agency protocols and procedures should reflect this up-to-date evidence. Periodic, competency-based evaluation of nurses' BP measurement skills is also needed. Moreover, nurses should take advantage of opportunities to contribute to the science of BP measurement through research in their respective settings. Through these various efforts, pediatric nurses can assure accurate BP measurement, and, ultimately, high quality care of their patients.


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Kathleen A. Schell, DNSc, RN, is Assistant Professor, School of Nursing, College of Health Sciences, University of Delaware, Newark, DE.
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Author:Schell, Kathleen A.
Publication:Pediatric Nursing
Geographic Code:1USA
Date:May 1, 2006
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