This guideline offers a definition of blood pressure as well as describing the benefits and difficulties of various techniques of measure BP in infants, children and young people.
- Users should be aware that for children and young people experiencing abnormal heart rhythms, weak pulse, very low or very high blood pressure, muscle tremors or any movement during the BP measurement with automated devices may fail to obtain a reading and will either indicate an error code or give unreliable results (Rationale 1).
- Incorrect cuff size is a major source of error for both automated blood pressure measuring devices and manual sphygmomanometers/doppler. An under-sized cuff can significantly over-estimate blood pressure.
- Incorrect cuff placement can also be a major source of error, this is particularly important in infants and young children. The cuff should be placed on the arm with the centre of the bladder over the brachial artery. A cuff that encircles close to 100% of the upper arm circumference will reduce the risk of cuff error significantly.
Blood pressure (BP) is defined as "… the amount of pressure exerted on the wall of the arteries as the blood moves through them. It is a continuous variable with two measurements recorded- systolic and diastolic” (Spiby 2010). There are two main phases of a BP: the systolic phase and the diastolic phase. The systolic represents the pressure in the artery when the heart is contracting and the diastolic the lowest pressure when the heart is at rest between beats (Spiby 2010).
A BP is made up of five Korotkoff sounds, which are defined as follows:
Phase 1: the first appearance of faint, repetitive, clear tapping sounds that gradually increase in intensity for at least two consecutive beats – this is the systolic BP.
Phase 2: a brief period may follow during which the sounds soften and acquire a swishing quality. An auscultatory gap may occur here in some patients (usually elderly and hypertensive patients) – this is where sounds may disappear altogether for a short time.
Phase 3: the return of sharper sounds, which become crisper to regain, or even exceed, the intensity of Phase 1 sounds.
The clinical significance, if any, of Phases 2 and 3 has not been established.
Phase 4: the distinct, abrupt muffling sounds, which become soft and blowing in quality.
Phase 5: the point at which all sounds finally disappear completely – in adults this is the diastolic pressure (although this is under debate) and current recommendations suggest that both Phase 4 and Phase 5 should be recorded.
How to measure systolic blood pressure using a Doppler and Greenlight300 TM sphygmomanometer
- Ensure the child is comfortable.
- Apply the cuff ensure the internal bladder encircles 90-100 per cent of the upper arm circumference.
- The arrow on the cuff should be placed over the brachial artery.
- The first BP reading should be estimated by placing a Doppler over the pulse and pumping up the cuff. When the pulse sound disappears this is your estimated BP. Now deflate the cuff quickly.
- Keep the Doppler over the pulse; pump the cuff up to a pressure 30mmHg higher than the estimated BP.
- Reduce the pressure slowly (you should see a green light on the right hand size of the monitor; this indicates that the pressure is reduced at the correct speed).
- The first repetitive sound is recorded as the systolic BP.
- If you need to repeat the BP you should wait one minute to give the vessels a chance to refill.
- Record the systolic BP measurement immediately on nervecentre / carevue /CEWS chart as appropriate.
To obtain a diastolic reading use a stethoscope rather than Doppler. For instructions on how to measure BP with a stethoscope, please refer to ausculation section below.
Frequency of BP measurement
A BP should be measured on all children/young people admitted to hospital (Royal College of Nursing, 2013). If the measurement is considered within normal ranges for the child/young person and there are no other indications for a BP to be performed this may be the only BP measurement required (Brennan 2002). A BP should be measured regularly and/or monitored in line with the Observation and CEWS Policy:
A BP should be measured in the following circumstances:
- If the initial reading is shown to be outside normal ranges (appendix 2, 3, 4).
- For children/young people with a family history of hypertension (Rationale 2).
- For all children/young people with renal or urological impairment (Rationale 3).
- For children/young people with cardiac impairment (Rationale 4).
- For children/young people with diabetes (Rationale 5).
- If a child/young person is pregnant (Rationale 6).
- During a critical illness (Rationale 7).
- If the child/young person has any deterioration in neurological status (Rational 8).
- Before an antihypertensive medication or any other medication that may affect the blood pressure is administered (Rationale 9).
- According to specific existing protocols, such as during albumin infusion or blood transfusion and when the child/young person is receiving an intravenous infusion (Rationale 10).
- A BP will need to be measured regularly and/or monitored (according to the child’s/young person's condition and local protocols).
- For children/young people peri-operatively and post surgery (Hockenberry and Wilson, 2012).
At the initial examination, a BP should be performed on the right arm. For infants and specific medical conditions, a BP measurement on both arms and legs should be performed (National High Blood Pressure Education Program Working Group, 2004). If a child is found to be hypertensive a BP should be measured on both arms and the arm with the highest reading should then be used (Spiby 2010) (Rationale 11).
Methods of blood pressure monitoring
There are two main methods of BP monitoring, direct and indirect:-
A direct BP can only be performed when the child has an arterial line in situ, but it is regarded as the 'gold standard' or 'true' BP. This is rarely performed outside of intensive care units, high dependency care units and renal transplant centres (Hignett and Stephens, 2006) (Rationale 12).
Indirect methods are more commonly performed and there are several different ways to achieve this:
- auscultation (sphygmomanometer with stethoscope)
- Doppler (sphygmomanometer with Doppler)
- palpation (sphygmomanometer with palpation)
- oscillometry (Philips or similar)
Auscultation, Doppler and palpation are known as 'manual' BP measurements whereas oscillometry (along with some automated Doppler machines) are 'automated' methods of BP measurement.
Automated BP monitors measure the blood pressure by calculating the pressure using an algorithm. The algorithm is different for each manufacturer. Very few monitors have been validated for use in children and those that have, have only been validated for use in normotensive children. For this reason The British Hypertension Society (2012) states that the validation in hypertensive children is questionable. The evidence based on the current literature concludes that oscillometric (automated) devices significantly overestimate both the systolic and diastolic blood pressure in children/young adults (Flynn et al 2012). Lurbe et al (2009) and the National High Blood Pressure Education Program Working Group (2004) recommend that all BP measured on automated monitors that are found to be >90th percentile for age and height should be re-measured manually before making a diagnosis of hypertension. In practice most health care professionals managing hypertension in children and young adults prefer using manual blood pressure techniques (Brennan 2012).
The equipment required should be gathered and checked prior to performing the BP (Rationale 15). This should be cleaned according to the hospital policy.
- Light or dial:
- on zero
- not obscured
- Maintenance/recalibration (Rationale 16):
- They should be serviced yearly by biomedical engineering department to confirm accuracy
- Date of last calibration should be clearly stated on the manometer
- Bladder, tubing, connections, inflation bulb and valves are sound
- Nylon cuffs should be wiped with disinfectant wipes between patients
- Fabric cuffs should be washed regularly
- Disposable or single patient use cuff should be used for children who are considered infectious or immunocompromised.
- good condition
- secure fastening
- correct size
Equipment for manual measurement
- Inflation/deflation device:
- Control valves, leaks, vents, tubing - should be clean and not perished.
- The system must be able to inflate rapidly.
- Deflation should be smooth and able to be reduced at 2-mmHg/second (Stethoscope or Doppler and water soluble jelly. Do not use KY Jelly as this erodes the transducer) (Parks Medical 2002).
- Good condition, with clean well-fitting earpieces (Beevers et al 2001a).
- Clean (using water not alcohol) (Parks Medical 2002).
- Used according to manufacturer's guidelines.
- An automated blood pressure monitor:
- Refer to manufacturer's guidelines.
- Choose cuff size according to guidelines below not according to the label on the cuff (infant, small child) (Rationale 17).
Choosing the correct cuff size
The inflatable part of the cuff (bladder) should cover a minimum of 90 per cent and preferably 100 per cent of the circumference of the arm). The width of the bladder should ideally be the full length from under the arm auxilla to the olecranon (elbow) or the largest cuff that can fit onto the upper arm and still allow auscillation of the brachial artery (Rationale 18). If these criteria cannot both be met, the largest cuff available for the arm should be used (Rationale 19) (Beevers et al 2001a).
Undertaking the procedure
- Wash hands before carrying out the procedure (Rationale 20) (Hand Hygiene guideline).
- Explain procedure to child/young person (Rationale 21):
- warn of minor discomfort that may be caused
- explain that the procedure may be repeated
The child/young person should ideally be asked to sit quietly for three to five minutes and wait 30 minutes after having eaten, exercised, had a conversation, drunk any coffee or drinks containing caffeine or had a cigarette (Rational 22) (Spiby 2010).
Automated measurement of blood pressure
As few monitors have been validated for use in paediatrics and those that have are not validated for children with high BP (British Hypertension Society, 2012), they cannot be recommended for use in younger children with high blood pressure. A manual BP should be measured
Care should be taken if an oscillometric device inflates and deflates repeatedly 'hunting' without displaying the BP; this can indicate the BP is either too low or high for the automated monitor to register (Lurbe et al 2009). If this occurs, a manual BP should be measured.
Automated devices tend to under-read at low BP and over-read very high BP.
Position the manometer
- It should be:
- Posture of patient:
Taking a blood pressure
- Ensure the area is child friendly and that they are comfortable in the environment (Rationale 28).
- Tight or restrictive clothing should be removed from the arm/leg
- Apply the cuff and ensure the centre of the bladder marked with an arrow is placed over the bracial artery. This should fit firmly and be well secured (Rationale 29) (Spiby 2010). The lower edge of the bladder should be one centimetre above the tubing from the blood pressure cuff and should not cross the auscultatory area (Rationale 30). The exception to this would be children who need long cuffs for large arm circumference. If the cuff covers the brachial area the radial pulse should be used.
- The tubing may lie inferior (going down), superior (going up) or posterior (at the back) (Rationale 31).
- The arm should be well supported at the level of mid-sternum (Rationale 32).
- The first BP reading should be estimated by palpation.
- Palpate over artery, place the stethoscope/Doppler/fingers over the pulse. Do not press too firmly or touch the cuff (Rationale 33).
- Inflate the cuff over three to five seconds. When the pulse sound disappears this is your estimated BP. Now deflate the cuff quickly (Beevers et al 2001b) (Rationale 34).
- Place the Doppler/stethoscope just above the antecubital fossa where you will hear the maximal pulsation of the brachial artery in the arm (Rationale 35).
- Inflate the bladder once again steadily to a pressure of 30mmHg above the previously estimated systolic BP (McAlister & Straus 2001) (Rationale 36).
- Reduce the pressure at 2-3mmHg per second (Rationale 37). If you are using the Greenlight 300TM a green light appears on the bottom right hand side of the monitor indicating deflation speed is correct.
- The point at which the first repetitive, clear tapping sounds (Phase 1) first appear for at least two consecutive beats gives the SYSTOLIC BP (McAlister & Straus 2001).
- The point at which the repetitive sounds disappear (Phase 5) gives the DIASTOLIC BP (McAlister & Straus 2001). Note: a Doppler will not record the diastolic BP. If a diastolic BP is required, a stethoscope is required (Rationale 38).
- Then continue to completely deflate the cuff rapidly (McAlister & Straus 2001).
- All measurements should be taken to the nearest 2mmHg (Beevers et al 2001b) (Rationale 39). A diastolic BP Phase 5 may not be present in some groups of children. For these children, the diastolic BP should be recorded at the point where muffling of the repetitive sounds is taken (Phase 4). This should be clearly documented as Phase 4.
- There may be a 'silent' or 'auscultatory gap' where sounds disappear shortly after the systolic phase is heard. This should be documented if it is noted – care must be taken to ensure that the systolic phase is heard and the return of the sounds after the gap are not thought to be the systolic BP.
- If the reading is difficult to ascertain – which is common in small, unsettled infants – it may be easier to find a second person to assist with the measurement (Rationale 40).
- If it is necessary to repeat the BP, the cuff should be allowed to fully deflate, and a minute should elapse before the next measurement is taken (Brennan 2002) (Rationale 41).
- Automated devices may fail to obtain a reading and will either indicate an error code or give unreliable results; manufacturers warn that clinical judgement should be used in the appropriateness of using an automated monitor for children and young people with some clinical conditions. (Rationale 42).
- Ensure the correct patient setting is set on the monitor (neonate, paediatric, adult) and press the start button as recommended by the manufacturers. Set the monitor for a single measurement or automatic measurement for the frequency required as recommended in the manufacturer's guide. The cuff should be reapplied frequently if regular BP monitoring is required (Rationale 43).
- Cuff should fit firmly and be well secured (Spiby 2010). Avoid using arms that has an intravenous infusion or cannula in place. (Medicines and Healthcare Products Regulatory Agency 2012) (Rationale 44).
- The arm should remain still during the measurement (Rationale 45).
- If the BP readings are above the expected level for age and height and the child is calm and not in any discomfort during the procedure the BP measurement should be repeated three times, leaving at least one minute between readings. Make sure the cuff bladder size is correct and continue to monitor. If the readings obtained are consistently high a four limb BP should be measured. If the problem continues, manual BP measurement should be obtained (Rationale 46) (follow flow chart).
- If the child’s BP is to be monitored continually make sure the cuff is not wrapped too tightly around the limb (Rationale 47).
- If it is necessary to repeat the BP, the cuff should be allowed to fully deflate, then a minute should elapse before the next measurement is taken (Beevers 2001a) (Rationale 48).
- Care should be taken if an oscillometric device inflates and deflates repeatedly 'hunting' without displaying the BP; this can indicate the BP is either too low or high for the automated monitor to register (Lurbe et al 2009). If this occurs, a manual BP should be measured (see the Measuring BP flow chart).
Recording a blood pressure
- The BP should be recorded on nervecentre / Carevue /CEWS chart as appropriate as soon as it is recorded (Rationale 49).
- The arm in which the pressure is being recorded and the position of the subject should be noted, for example, left arm – sitting (Rationale 50).
- The arm used, cuff size and method of measurement should be indicated.
- If the child/young person is anxious, restless or distressed, a note should be made with the BP ( Beevers et al 2001b).
Rationale 1: Oscillometry (automated) methods of BP measurement in children can be problematic; the accuracy of several models used by many paediatric areas has known limitations (Lurbe et al 2009; Flynn et al 2012). Oscillometric devices calculate BP from the oscillations detected in the cuff – this determines the mean BP directly from the maximum point of oscillation – the systolic and diastolic are then calculated using an algorithm (Lurbe et al 2009). The problem with this method is that the oscillation in children is often short so the potential for erroneous measurements is increased significantly (Lurbe et al 2009) leading to an increased variability in measurements. Very few monitors have been validated for paediatrics and those that have are not validated for children with high BP (British Hypertension Society, 2012). For this reason they cannot be recommended in younger children with high blood pressure.
Rationale 2: Research suggests that many children can have a high BP of unknown origin (or primary hypertension). Contact with health care professionals allows this to be measured, recorded and if necessary followed up (National High Blood Pressure Education Program Working Group (2004). Hypertension can run in families (Spiby, 2010).
Rationale 4: Cardiac disease can cause an alteration in BP due to altered cardiac contractility (Edwards 1997).
Rationale 5: To detect hypertension and allow treatment to commence, to reduce the comorbidities of children and young people with diabetic kidney disease and eye disease (Adler et al 2000).
Rationale 6: Hypertension is common in pregnant women (Beevers et al 2001a).
Rationale 7: Changes in BP can indicate hypovolaemia, sepsis, shock, or be a side effect of anaesthetic drugs (Wong 2012).
Rationale 8: BP can increase as a result of neurological damage
Rational 9: A child’s blood pressure should always be measured before giving anti hypertension medication to ensure they still require the medication as prescribed
Rationale 10: An altered BP can indicate that a change to treatment may be necessary or that action should be taken (for example indicate an altered fluid status during albumin infusion or a reaction to blood transfusion).
Rationale 11: To assess for pressure differences between arms, a difference in more than 20 may be an indication of cardiac congenital condition, a low BP in the legs and a high BP in the arms may indicate a coarctation
Rationale 12: Arterial lines are usually only used in critical care settings because of the associated risks with use, e.g. haemorrhage, thrombosis and infection.
Rationale 13: Because of greater accuracy and reproducibility (Flynn et al 2012)
Rationale 14: The Greenlight300TM is felt to be more accurate as it is self-calibrated and easier to maintain than previous manometers.
Rationale 15: To prevent additional distress to the child by delayed procedure (National High Blood Pressure Education Program Working Group, 2004).
Rationale 16: To ensure that it will provide an acceptably accurate measurement and meets recommendations. Literature has demonstrated that up to 50 per cent of BP measuring equipment is thought to be inaccurate and can result in the recording of an inaccurate BP (Medicines and Healthcare Products Regulatory Agency 2012: Coleman et al 2005).
Rational 17: The cuff should be measure against the child’s arm circumference and not chosen by the ‘label’ on the cuff as children arm circumference can vary considerably.
Rationale 18: To ensure that the most accurate BP reading can be made and avoid 'cuff hypertension' (Beevers et al 2001a). The arrow on the BP cuff should be placed over the brachial artery, this exact positioning can be difficult in infants and small children due to the size of the arm causing an effect of undercuffing (over estimating the blood pressure due to inadequate depression of the artery).
Rationale 19: Cuff size and positioning is crucial to an accurate BP measurement (Urbina et al 2008).
Rationale 20: To minimise spread of infection.
Rationale 21: To minimise any potential error in BP recording, due to Defence Reaction/‘White Coat’ Hypertension – this can cause an increase in BP and tends to subside when the child young adult becomes accustomed to the procedure and the observer.
Rationale 22: To minimise the risk of anxiety which may result in a temporarily elevated BP The child/young person should be informed of the need for BP measurement. If the child is anxious, the support of play therapists to allay anxiety before ambulatory blood pressure monitoring is undertaken, is recommended (Urbina et al 2008).
Rationale 23: To prevent observer error (Beevers et al 2001b).
Rationale 24: To prevent injury to the staff performing the blood pressure measurement.
Rationale 25: BP centiles are recorded on children in the seated position but, if the patient is lying down, the BP may read slightly lower (Beevers et al 2001a).
Rationale 26: To ensure that the procedure is performed accurately and on the first attempt to prevent unnecessary repeating of the procedure and further distressing the child.
Rationale 27: BP can be significantly increased by the patient’s legs being crossed (Keele-Smith and Price-Daniel 2001).
Rationale 28: To minimise the effect of extraneous influences which may, temporarily, alter the BP (Perloff et al 1993).
Rationale 29: Incorrect cuff placement can be a major source of error, this is particularly important in infants and young children.
Rationale 30: Contact of the stethoscope with the cuff tubing may produce artefactual sounds.
Rationale 31: To allow easy access to the auscultatory area (antecubital fossa) (Beevers et al 2001b).
Rationale 32: If the child’s arm is below heart level BP can be overestimated by 10mmHg and if above it can be underestimated by same amount (Petrie et al 1986).
Rationale 33: To avoid inaccuracies in BP measurement.
Rationale 34: To maximise the accuracy and reproducibility of the measurement (Lurbe et al 2009).
Rationale 35: Prevents underestimation of systolic pressure by misreading Korotkoff 3 sound after auscultatory gap as Korotkoff 1sound (Beevers et al 2001b).
Rationale 36: Slow inflation results in venous congestion (Nolan & Nolan 1993).
Rationale 37: Rapid deflation can result in recording errors (Nolan & Nolan 1993).
Rationale 38: Dopplers are the most accurate method of gaining a systolic reading in children under the age of five (Flynn et al 2012) However, they cannot reliably measure a diastolic pressure (Parks Medical 2002). A doppler will not pick up the diastolic BP because it only detects the acoustic waves moving towards the transducer as opposed to the sound.
Rationale 39: To avoid digit preference.
Rationale 40: To enable an accurate reading to be taken.
Rationale 41: To allow refilling of blood vessel.
Rationale 42: The manufacturers warn that clinical judgement should be used in the appropriateness of using an automated monitor on patients who are moving, shivering or convulsing, with cardiac arrhythmias, if the patient's BP is changing rapidly over a period of time (e.g. renal replacement therapy or fluid shifts), severe shock or hypothermia where blood flow to the peripheries is reduced, heart rate extremes (<40bpm->300bpm). Care must also be taken with patients who are obese as a thick layer of fat surrounding the arm dampens the oscillations coming from the artery, and accuracy is reduced.
Rationale 43: If the monitor inflation settings are too high this may cause considerable discomfort to the child and cause the BP to increase due to a pain response. Frequent repeated measurement can cause purpura, ischemia and neuropathy, for this reason the BP cuff should be reapplied hourly and the skin observed for colour, warmth and sensitivity.
Rational 44: The manufacturer's recommendations are not to measure BP on arms with infusions or cannula as there is an increased risk of tissue damage and extravasation (Medicines and Healthcare Products Regulatory Agency, 2012).
Rationale 45: Movement artefact or an irregular pulse can be responsible for false readings. In this situation a manual BP should be taken.
Rationale 46: The BP readings on automated monitors do tend to be slightly higher than manual readings on normotensive children (Spiby, 2010). For children who are hypertensive, the variability seems to be significant (Flynn et al 2012). To date there are no automated monometers that have been successfully validated for use in children with hypertension in the UK.
Rationale 47: This may cause discoloration and even ischemia.
Rationale 48: To prevent venous congestion which would give an inaccurate BP on the second reading (Nolan & Nolan 1993).
Rationale 49: To prevent the measurement being forgotten and ensure timely recording of observations in line with Observation and CEWS Policy.
Rationale 50: The same limb and cuff size should be used for repeated measurements to ensure consistency.
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