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Distribution of 24-h ambulatory blood pressure in children: normalized reference values and role of body dimensions

Wühl, Elkea; Witte, Klausb; Soergel, Mariannec; Mehls, Ottoa; Schaefer, Franz*for the German Working Group on Pediatric Hypertension

Origianl Papers: Blood pressure measurement: Original article

Background  Twenty-four-hour ambulatory blood pressure monitoring (ABPM) is an essential tool in the diagnosis and therapeutic monitoring of arterial hypertension in children. The statistical use of pediatric ABPM reference values has been compromised by the non-Gaussian distribution of 24-h blood pressure (BP) in children.

Objective  To develop distribution-adjusted pediatric ABPM reference tables.

Methods  From cross-sectional ABPM data obtained in 949 healthy children and adolescents aged 5–20 years, a set of reference tables was developed for 24-h, daytime and night-time mean values of systolic, diastolic, mean arterial BP and heart rate, utilizing the LMS method to account for the variably skewed distribution of ABPM data. Age- and gender-specific estimates of the distribution median (M), coefficient of variation (S) and degree of skewness (L) were obtained by a maximum-likelihood curve-fitting technique. The estimates of L, M and S can be used to normalize ABPM data to gender and age or height.

Results  Re-application of the established L, M and S values in the reference population confirmed appropriate normalization of ABPM values. Height standard deviation scores (SDS), body mass index (BMI) SDS and heart rate SDS were independent positive predictors of 24-h systolic BP SDS. Diastolic 24-h mean BP SDS showed a weak correlation with BMI SDS only.

Conclusions  The use of LMS reference tables permits calculation of appropriate SDS values for ABPM in children. Whereas systolic 24-h BP is independently correlated with age, relative height and obesity, diastolic values are almost independent of age and relative height, and weakly associated with relative obesity.

aDivision of Pediatric Nephrology, University Children's Hospital and bInstitute of Pharmacology and Toxicology, Faculty for Clinical Medicine Mannheim, University of Heidelberg, Germany and cCentre Hospitalier Luxembourg, Luxembourg.

Sponsorship: This work was supported by grants from the Boehringer Ingelheim Fund, Aventis Pharma and the Baxter Extramural Grant Program.

Correspondence and requests for reprints to Dr. Franz Schaefer, Division for Pediatric Nephrology, University Children's Hospital, Im Neuenheimer Feld 150, 69120 Heidelberg, Germany. Tel: +49 6221 563 2396; fax: +49 6221 564203; e-mail:

Received 14 January 2002

Revised 14 May 2002

Accepted 24 June 2002

See editorial commentary page 1939

*Members of the German Working Group on Pediatric Hypertension: Marianne Soergel (coordinator), Martin Kirschstein, Christopher Busch, Thomas Danne, Jutta Gellermann, Reinhard Holl, Friedrich Krull, Hagen Reichert, György S. Reusz, Wolfgang Rascher.

© 2002 Lippincott Williams & Wilkins, Inc.