European Journal of Pediatrics

, Volume 177, Issue 2, pp 205–210 | Cite as

Influence of blood pressure level and age on within-visit blood pressure variability in children and adolescents

  • Panagiota Veloudi
  • Christopher L. Blizzard
  • Velandai K. Srikanth
  • Martin G. Schultz
  • James E. Sharman
Original Article


Blood pressure (BP) is variable in children and this could affect BP assessment, but the magnitude of within-visit BP variability (BPV) over consecutive measurements has never been investigated. This study aimed to determine the direction and magnitude of, and factors affecting, within-visit BPV in children and adolescents. BP was recorded among 3047 children (aged 12 years [95%CI 12, 13], males 52%) from the 2011–2013 Australian Health Survey. BPV was defined as the absolute difference (∆SBPABS) between the first (SBP1) and second systolic BP (SBP2) and the overall variability in three measures when available (SBPV). On average, ∆SBPABS was 6.7 mmHg (95%CI 6.3, 7.0) and SBPV was 8.2% (95%CI 7.8, 8.6). ∆SBPABS was greater with higher BP levels but lower with older age. From first to second measurements, SBP decreased in 58% (95%CI 56, 60), did not change in 10% (95%CI 9, 12), and increased in 32% (95%CI 29, 34) of the population.

Conclusions: BP is highly variable in children and adolescents, with the magnitude of variability being associated with both age and BP level. SBP increases on repeat measurement in a substantial proportion of the population. The optimal protocol of BP assessment to address this increased BPV needs to be determined.

What is Known:

Diagnosis of elevated blood pressure (BP) is based on strict probabilistic criteria, the difference between the 90th (pre-hypertension) and 95th (hypertension) percentiles only being 3–4 mmHg.

• BP variability could affect BP classification among children and adolescents.

What is New:

The magnitude of BP change among children and adolescents is highly affected by BP level and age.

• BP does not always drop on consecutive measurements, and evidence-based BP assessment protocols should be established to avoid misdiagnosis of hypertension.


Blood pressure classification Clinic blood pressure Alarm reaction Pediatric hypertension Hypertension guidelines 



Australian Health Survey


Blood pressure


Blood pressure variability


Body mass index


Diastolic blood pressure


Variability in diastolic blood pressure


Difference between SBP1 and SBP2


Absolute difference between SBP1 and SBP2


Pulse pressure


First systolic blood pressure


Second systolic blood pressure


Third systolic blood pressure


Variability in systolic blood pressure


Authors’ contributions

Veloudi, P.: Mrs Veloudi contributed to study conception and design, literature review, data analysis and interpretation, manuscript preparation and final approval of the version to be published.

Blizzard, C.L.: A/Prof Blizzard contributed to data analysis and interpretation, critical manuscript revision and final approval of the version to be published.

Schultz, M.G.: Dr Schultz contributed to critical manuscript revision and final approval of the version to be published.

Srikanth, K.V.: Prof Srikanth contributed to critical manuscript revision and final approval of the version to be published.

Sharman, J.E.: Prof Sharman contributed to study conception and design, critical manuscript revision and final approval of the version to be published.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Informed consent

Informed consent was obtained from all individual participants included in the study.

Supplementary material

431_2017_3049_MOESM1_ESM.docx (15 kb)
ESM 1 (DOCX 15 kb).


  1. 1.
    Munter P, He J, Cutler JA, Wildman RP, Whelton PK (2004) Trend in blood pressure among children and adolescents. JAMA 291:2133CrossRefGoogle Scholar
  2. 2.
    Aatola H, Hutri-Kahonen N, Juonala M, Viikari JS, Hulkkonen J, Laitinen T, Taittonen L, Lehtimaki T, Raitakari OT, Kahonen M (2010) Lifetime risk factors and arterial pulse wave velocity in adulthood: the cardiovascular risk in young Finns study. Hypertension 55(3):806–811. CrossRefPubMedGoogle Scholar
  3. 3.
    Hanevold C, Waller J, Daniels S, Portman R, Sorof J, International Pediatric Hypertension A (2004) The effects of obesity, gender, and ethnic group on left ventricular hypertrophy and geometry in hypertensive children: a collaborative study of the International Pediatric Hypertension Association. Pediatrics 113(2):328–333. CrossRefPubMedGoogle Scholar
  4. 4.
    Sorof JM, Alexandrov AV, Cardwell G, Portman RJ (2003) Carotid artery intimal-medial thickness and left ventricular hypertrophy in children with elevated blood pressure. Pediatrics 111(1):61–66. CrossRefPubMedGoogle Scholar
  5. 5.
    Berenson GS, Wattigney WA, Tracy RE, Newman WP 3rd, Srinivasan SR, Webber LS, Dalferes ER Jr, Strong JP (1992) Atherosclerosis of the aorta and coronary arteries and cardiovascular risk factors in persons aged 6 to 30 years and studied at necropsy (The Bogalusa Heart Study). Am J Cardiol 70(9):851–858. CrossRefPubMedGoogle Scholar
  6. 6.
    Mitchell P, Cheung N, de Haseth K, Taylor B, Rochtchina E, Islam FM, Wang JJ, Saw SM, Wong TY (2007) Blood pressure and retinal arteriolar narrowing in children. Hypertension 49(5):1156–1162. CrossRefPubMedGoogle Scholar
  7. 7.
    Moyer VA (2013) Screening for primary hypertension in children and adolescents: U.S. preventive services task force recommendation statement. An Intern Med 159:613–619CrossRefGoogle Scholar
  8. 8.
    Eliasdottir SB, Steinthorsdottir SD, Indridason OS, Palsson R, Edvardsson VO (2013) Comparison of aneroid and oscillometric blood pressure measurements in children. J Clin Hypertens (Greenwich) 15(11):776–783. CrossRefGoogle Scholar
  9. 9.
    Falkner B, Daniels SR (2004) Summary of the fourth report on the diagnosis, evaluation, and treatment of high blood pressure in children and adolescents. Hypertension 44(4):387–388. CrossRefPubMedGoogle Scholar
  10. 10.
    Lurbe E, Agabiti-Rosei E, Cruickshank JK, Dominiczak A, Erdine S, Hirth A, Invitti C, Litwin M, Mancia G, Pall D, Rascher W, Redon J, Schaefer F, Seeman T, Sinha M, Stabouli S, Webb NJ, Wuhl E, Zanchetti A (2016) 2016 European Society of Hypertension guidelines for the management of high blood pressure in children and adolescents. J Hypertens 34(10):1887–1920. CrossRefPubMedGoogle Scholar
  11. 11.
    Veloudi P, Blizzard CL, Srikanth V, Breslin M, Sharman JE (2017) Age-dependent changes in blood pressure over consecutive office measurements: impact on hypertension diagnosis and implications for international guidelines. J Hypertens 35(4):753–760. CrossRefPubMedGoogle Scholar
  12. 12.
    Shankar RR, Eckert GJ, Saha C, Tu W, Pratt JH (2005) The change in blood pressure during pubertal growth. J Clin Endocrinol Metab 90(1):163–167. CrossRefPubMedGoogle Scholar
  13. 13.
    Bonso E, Ragazzo F, Palatini P (2008) Validation of A&D UA-85X device for blood pressure measurement. Blood Press Monit 13(6):339–341. CrossRefPubMedGoogle Scholar
  14. 14.
    Negroni-Balasquide X, Bell CS, Samuel J, Samuels JA (2016) Is one measurement enough to evaluate blood pressure among adolescents? A blood pressure screening experience in more than 9000 children with a subset comparison of auscultatory to mercury measurements. J Am Soc Hypertens 10(2):95–100. CrossRefPubMedGoogle Scholar
  15. 15.
    Rosner B, Cook NR, Evans DA, KEough ME, Taylor JO, Polk BF, Hennekens CH (1987) Reproducibility and predictive values of routine blood pressure measurements in children. Am J Epidemiol 126(6):1115–1125. CrossRefPubMedGoogle Scholar
  16. 16.
    Kawabe H, Saito I, Saruta T (2005) Influence of repeated measurement on one occasion, on successive days, and on workdays on home blood pressure values. Clin Exp Hypertens 27(2-3):215–222. CrossRefPubMedGoogle Scholar
  17. 17.
    Mancia G, Fagard R, Narkiewicz K, Redon J, Zanchetti A, Bohm M, Christiaens T et al (2013) 2013 ESH/ESC guidelines for the management of arterial hypertension: the task force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC). J Hypertens 31(7):1281–1357. CrossRefPubMedGoogle Scholar
  18. 18.
    Woroniecki RP, Flynn JT (2005) How are hypertensive children evaluated and managed? A survey of North American pediatric nephrologists. Pediatr Nephrol 20(6):791–797. CrossRefPubMedGoogle Scholar
  19. 19.
    Jafar TH, Islam M, Poulter N, Hatcher J, Schmid CH, Levey AS, Chaturvedi N (2005) Children in South Asia have higher body mass-adjusted blood pressure levels than white children in the United States: a comparative study. Circulation 111(10):1291–1297. CrossRefPubMedGoogle Scholar
  20. 20.
    Papandreou D, Stamou M, Malindretos P, Rousso I, Mavromichalis I (2007) Prevalence of hypertension and association of dietary mineral intake with blood pressure in healthy schoolchildren from northern Greece aged 7-15 years. Ann Nutr Metab 51(5):471–476. CrossRefPubMedGoogle Scholar
  21. 21.
    de Moraes AC, Carvalho HB, Siani A, Barba G, Veidebaum T, Tornaritis M, Molnar D, Ahrens W, Wirsik N, De Henauw S, Marild S, Lissner L, Konstabel K, Pitsiladis Y, Moreno LA, Consortium I (2015) Incidence of high blood pressure in children—effects of physical activity and sedentary behaviors: the IDEFICS study: high blood pressure, lifestyle and children. Int J Cardiol 180:165–170CrossRefGoogle Scholar
  22. 22.
    Dong B, Wang Z, Song Y, Wang HJ, Ma J (2015) Understanding trends in blood pressure and their associations with body mass index in Chinese children, from 1985 to 2010: a cross-sectional observational study. BMJ Open 5(9):e009050. CrossRefPubMedPubMedCentralGoogle Scholar
  23. 23.
    Monyeki KD, Kemper HC, Makgae PJ (2008) Relationship between fat patterns, physical fitness and blood pressure of rural South African children: Ellisras Longitudinal Growth and Health Study. J Hum Hypertens 22(5):311–319. CrossRefPubMedGoogle Scholar
  24. 24.
    Chiolero A, Cachat F, Burnier M, Paccaud F, Bovet P (2007) Prevalence of hypertension in schoolchildren based on repeated measurements and association with overweight. J Hypertens 25(11):2209–2217. CrossRefPubMedGoogle Scholar
  25. 25.
    Sorof JM, Lai D, Turner J, Poffenbarger T, Portman RJ (2004) Overweight, ethnicity, and the prevalence of hypertension in school-aged children. Pediatrics 113(3):475–482. CrossRefPubMedGoogle Scholar
  26. 26.
    McNiece KL, Poffenbarger TS, Turner JL, Franco KD, Sorof JM, Portman RJ (2007) Prevalence of hypertension and pre-hypertension among adolescents. J Pediatr 150:640–644 644 e641CrossRefGoogle Scholar
  27. 27.
    Kagura J, Adair SL, Pisa TP, Griffiths LP, Pettitor MJ, Norris AS (2016) Association of socioeconomic status change between infancy and adolescence, and blood pressure, in South African young adults: birth to twenty cohort. BMJ Open 6(3):e008805. CrossRefPubMedPubMedCentralGoogle Scholar
  28. 28.
    Wirix AJ, Nauta J, Groothoff JW, Rabelink TJ, HiraSing RA, Chinapaw MJ, Kist-van Holthe JE (2016) Is the prevalence of hypertension in overweight children overestimated? Arch Dis Child 101(11):998–1003. CrossRefPubMedGoogle Scholar
  29. 29.
    Myers MG, Valdivieso M, Kiss A (2009) Use of automated office blood pressure measurement to reduce the white coat response. J Hypertens 27(2):280–286. CrossRefPubMedPubMedCentralGoogle Scholar
  30. 30.
    Pandit JA, Batlle D (2015) Snapshot hemodynamics and clinical outcomes in hypertension: precision in the measurements is key. Hypertension 67(2):270–271. CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2017

Authors and Affiliations

  • Panagiota Veloudi
    • 1
  • Christopher L. Blizzard
    • 1
  • Velandai K. Srikanth
    • 1
    • 2
  • Martin G. Schultz
    • 1
  • James E. Sharman
    • 1
  1. 1.Menzies Institute for Medical ResearchUniversity of TasmaniaHobartAustralia
  2. 2.Department of Medicine, School of Clinical Sciences at Monash HealthMonash Medical CentreMelbourneAustralia

Personalised recommendations