• All children aged 3 years or older who are seen
in any medical setting should have their blood pressure (BP) measured.
• BP is a primary measure of cardiac output in acute assessment
of any potentially compromised patient.
• BP change over time allows monitoring of changing hemodynamic
status and of response to intervention.
• In critical care settings, BP is best monitored by arterial line,
since peripheral measures can be inaccurate when cardiac output
• BP measurement is not recommended as a routine
in well children less than 3 years of age.
• However, specific conditions signal the need for BP determination
beginning in infancy and include the following:
• History of prematurity, very low birth weight, or any problem
requiring neonatal intensive care.
• Congenital heart disease (repaired or unoperated).
• Recurrent urinary tract infections, hematuria, or proteinuria.
• Renal or urologic disease.
• Family history of renal disease.
• Solid organ transplant, malignancy, or bone marrow transplant.
• Treatment with drugs known to raise BP.
• Systemic illnesses associated with hypertension.
• Increased intracranial pressure.
• BP should be measured using a standard clinical
sphygmomanometer on the upper right arm and a stethoscope over the
brachial artery pulse, just below the cuff.
• Automated oscillometric BP devices are convenient and reduce
observer error, but they do not provide exactly comparable results
to the auscultatory method.
• However, because of their ease of use, these devices are valuable
as a screening method and in intensive care settings.
• Abnormal readings must be confirmed by auscultation.
• Correct BP measurement requires a cuff size appropriate to the
size of the child; this means a range of sizes, including a large
adult cuff and thigh cuff, must always be available.
• An appropriate cuff meets the following criteria:
• Height of the inflatable bladder is at least 40% of
the arm circumference at a point midway between the olecranon and
• Bladder length should cover > 80% of the arm’s
circumference (bladder width-to-length ratio ≥ 1:2).
• Practically speaking, this means the cuff selected must be large
enough to cover the majority of the upper arm with just room for
the head of the stethoscope in the cubital fossa (Figure
Proper size and placement of blood pressure cuff.
• Whenever upper extremity hypertension is diagnosed,
lower extremity BPs and pulses should be obtained and compared to
exclude the possibility of coarctation of the aorta, which is the
most commonly missed congenital heart diagnosis.
• In children over 10 years of age, white coat hypertension is
• It is defined as elevated BP in medical settings but normal
pressure at all other times.
• This can be diagnosed by the use of ambulatory BP monitoring,
which allows computation of mean wake ...
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