Out-of-Office Blood Pressure
in Children and Adolescents: Disparate Findings
by Using Home or Ambulatory Monitoring
George S. Stergiou, Christina V. Alamara, Chrysa B. Kalkana,
Iraklis N. Vaindirlis, Constantinos J. Stefanidis,
Catherine Dacou-Voutetakis, and Theodore D. Mountokalakis
Background: The validity of home blood pressure
(HBP) measurements in children has not been evaluated,
although in clinical practice such measurements are being
used. This study compares HBP, with clinic (CBP) and
daytime ambulatory blood pressure (ABP) in children and
Methods: Fifty-five children and adolescents aged 6 to
18 years were evaluated with CBP (three visits), HBP (6
days), and daytime ABP. Mean age was 12.3 ? 2.9 (SD)
years, 33 boys. According to the Task Force CBP criteria,
26 were hypertensives, 6 had high-normal BP (hyperten-
sive group), and 23 were normotensives (normotensive
Results: In the hypertensive group, CBP was 130.8 ?
7.6/72.5 ? 8.1 mm Hg (systolic/diastolic), HBP 118.9 ?
6.3/73.7 ? 6.7, and ABP 130.8 ? 8.1/75.5 ? 8.3. In the
normotensive group, CBP was 112.8 ? 8/63.1 ? 6.3, HBP
106.7 ? 8.4/67.2 ? 5.2, and ABP 123.9 ? 7.2/72 ? 4.3.
Strong correlations (P ? .001) were observed between
this method in clinical practice because it is devoid of the
white coat effect and the placebo effect, provides informa-
tion on the response to antihypertensive treatment, and
may improve the patient’s adherence to treatment.2–4Re-
cently, it has been suggested that home blood pressure
(HBP) monitoring may also be useful in children, because
it may provide a better estimate of the true BP.5,6
There is evidence that in clinical practice HBP is
being used for the evaluation of out-of-office BP in
CBP–HBP (r ? 0.73/0.57, systolic/diastolic), CBP–ABP
(r ? 0.59/0.49), and HBP–ABP (r ? 0.72/0.66). In nor-
motensive subjects, ABP was higher than both CBP and
HBP for systolic and diastolic BP (P ? .001). Further-
more, systolic HBP was lower than CBP (P ? .01),
whereas the opposite was true for diastolic BP (P ? .05).
In hypertensive subjects systolic HBP was lower than both
CBP and ABP (P ? .001), whereas CBP did not differ
from ABP. For diastolic BP no differences were found
among measurement methods.
Conclusions: These data suggest that, in contrast to
adults in whom HBP is close to the levels of daytime ABP,
in children and adolescents HBP appears to be signifi-
cantly lower than daytime ABP. Until more data become
available, caution is needed in the interpretation of HBP in
children and adolescents.
869–875 © 2004 American Journal of Hypertension, Ltd.
Am J Hypertens 2004;17:
Key Words: Children, adolescents, home blood pres-
sure, ambulatory blood pressure, hypertension.
onitoring of blood pressure (BP) by patients at
home is being increasingly used in several coun-
tries.1Official guidelines recommend the use of
children and adolescents.6A recent survey in Germany
showed that more than 70% of pediatric nephrologists
recommend HBP monitoring for children with renal
disease or hypertension.6In this survey HBP was con-
sidered more important than clinic BP (CBP) measure-
ments by 64% of the nephrologists but less important
than ambulatory BP (ABP) monitoring by 67%.6How-
ever, physicians’ opinions on the usefulness of HBP in
children are based on evidence from clinical trials per-
formed exclusively in adults because no studies using
HBP monitoring in children have been published. The
objective of this study was to evaluate HBP measure-
Received February 5, 2004. First decision March 30, 2004. Accepted
May 10, 2004.
From the Hypertension Center, Third University Department of Med-
icine, Sotiria Hospital (GSS, CVA, CBK, TDM); Endocrine Unit, First
University Department of Pediatrics, Aghia Sophia Children’s Hospital
(INV, CD-V); and Department of Nephrology, P. & A. Kyriakou Chil-
dren’s Hospital (CJS), Athens, Greece.
Address correspondence and reprint requests to Dr. George S. Ster-
giou, Hypertension Center, Third University Department of Medicine,
Sotiria Hospital, 152 Mesogion Avenue, Athens 11527, Greece; e-mail:
AJH 2004; 17:869–875
0895-7061/04/$30.00 © 2004 by the American Journal of Hypertension, Ltd.
Published by Elsevier Inc. doi:10.1016/j.amjhyper.2004.05.015
ments in normotensive and hypertensive children and
adolescents in comparison with CBP and ABP measure-
Children and adolescents aged 6 to 18 years old referred
for elevated BP (on at least two occasions) were recruited.
Participants were asked to perform BP measurements in
the clinic, at home, and with ambulatory monitoring. Ex-
clusion criteria were history of hypertension, chronic dis-
ease, and treatment with antihypertensive or other
medication that might influence BP.
Participants were asked to measure HBP for 2 weeks or
ABP for 24 h. The alternate measurement was then per-
formed. CBP was measured in three visits within 3 weeks
when participants came to receive or to bring back the
devices for home or ambulatory BP monitoring.
CBP measurements were taken by three physicians who
fulfilled the British Hypertension Society Protocol criteria
for observer agreement in BP measurement.7Triplicate BP
measurements were taken at each clinic visit after 5 min of
sitting rest and with at least 1 min between recordings by
using a standard mercury sphygmomanometer (cuff with
bladder size 9 ? 18, 12 ? 23, or 15 ? 35 cm according to
arm circumference, Korotkoff phase V for diastolic BP, or
Korotkoff phase IV when sounds could be heard to 0 mm
HBP was measured using validated fully automated
electronic devices Omron HEM-705CP8(stores and prints
the last 12 measurements) or Omron IC8(stores all mea-
surements, which can be downloaded to a computer) (Om-
ron Healthcare GmbH, Hamburg, Germany; bladder size
12 ? 23 or 14 ? 28 cm where appropriate), apart from
children with arm circumference ?20 cm in whom the
Omron 711 IS was used (bladder size 9 ? 16 cm).9
Participants were trained in the conditions of HBP mea-
surement and the use of the electronic devices and were
instructed to make duplicate morning (6 to 10 AM) and
evening (6 to 10 PM) self-measurements after 5 min of
sitting rest and with 1 min between recordings, on 3
routine workdays per week for 2 weeks. In the younger
children, HBP measurements were taken by their parents.
In addition to the device memory storage and printout, a
form was supplied to the participants to report all HBP
ABP was measured using validated noninvasive porta-
ble oscillometric devices SpaceLabs 90207 or 90217
(SpaceLabs Inc., Redmond, WA; bladder size 12 ? 23 or
9 ? 16 cm where appropriate).8The recorders were pro-
grammed to measure BP at 20-min intervals for 24 h and
were applied always on a routine workday before or after
the HBP measurement period. Subjects were instructed to
follow their usual daily activities but to remain still with
the forearm extended during each BP reading. A brief
diary specifying the time when they went to bed and arose
was kept by the children or their parents. Before each HBP
or ABP monitoring session, the accuracy of the devices
was tested against a standard mercury sphygmomanometer
by manual activation (Y connector; three consecutive read-
ABP data and additional recorded information from the
report files generated by the ABP monitor were batch
imported and organized in a relational database (Microsoft
Access 2000, Redmond, WA) using a Visual Basic pro-
gram. This program, designed by Leonidas G. Roussias
(Athens, Greece) for statistical analysis of ABP-derived
data, reads the ASCII text files generated by the ABP
monitor and performs multiple data procedures and anal-
yses. ABP recordings with less than 30 successful awake
BP measurements or less than 12 sleeping measurements
were excluded from the analysis. The BP measurements
flagged by the software of the monitors as technically
erroneous were excluded as were measurements with sys-
tolic BP ?60 or ?260 mm Hg or with diastolic BP ?40
or ?150 mm Hg. Early readings taken less than 20 min
after the monitor was attached to patient were also ex-
cluded as these were taken in the clinic environment.
Average daytime, nighttime, and 24-h ABP were calcu-
lated according to individual subjects’ sleeping hours.
Subjects who provided less than 12 valid HBP readings
or readings taken on less than 4 days were excluded from
the analysis. All available HBP readings were averaged to
obtain the mean HBP per individual. The CBP measure-
ments of all the three study visits were also averaged to
give a single number per individual.
The criteria of 1996 Updated Task Force Report on
high blood pressure in children and adolescents10were
used for the classification of hypertension (mean CBP
?95th percentile for sex, age, and height), high-normal
blood pressure (90th to 95th percentile), and normotension
(?90th percentile). Diagnosis of ambulatory hypertension
was based on normative values of the German Working
Group on Pediatric Hypertension.11Using these normative
data, children and adolescents whose daytime ABP was
below the 90th percentile of daytime systolic and diastolic
BP, stratified according to gender and height were classi-
fied as normotensives.11Because of the lack of normative
data for HBP, classification of hypertension based on such
measurements was not performed.
Statistical analysis was performed using the MINITAB
INC Statistical Software (release 13.31) (Minitab Inc.,
PA). Student paired t tests were used for the comparison of
CBP, HBP, and ABP measurements with Bonferroni’s
correction for multiple comparisons applied where appro-
priate. Pearson correlations were used to investigate the
association of HBP with CBP and ABP. For a more
AJH–October 2004–VOL. 17, NO. 10 HOME BLOOD PRESSURE IN CHILDREN
meaningful evaluation of the differences between readings
obtained by various techniques in individual subjects, the
prediction error was also used as an absolute measure of
the amount of error in prediction. This was calculated, for
example, for HBP/CBP differences by calculating 100 ?
(HBP ? CBP)/CBP. Results are expressed as mean ?
standard deviation (SD). A probability value P ? .05 was
considered statistically significant.
A total of 57 consecutive children and adolescents, re-
ferred for elevated BP from February 2000 to April 2003,
were recruited. All referred children and adolescents were
invited to participate, apart from those who did not fulfill
the study inclusion criteria or lived a distance from Ath-
ens. Two recruited subjects were excluded because they
provided inadequate HBP measurements and data from 55
subjects (33 boys and 22 girls) were analyzed (mean age
12.3 ? 2.9 [SD] years, range 6 to 18). According to the
Task Force criteria for CBP measurement,1026 subjects
were classified as hypertensives, of which 20 (76%) had
only elevated systolic BP, 6 (24%) had elevated systolic
and diastolic BP, and none had only elevated diastolic BP.
Six subjects were classified as having high-normal BP due
to isolated elevation of systolic BP and 23 subjects were
classified as normotensives.
Comparison of CBP, HBP, and ABP revealed similar
findings for subjects with high to normal blood pressure
and hypertensives, which differed from normotensives.
Therefore, all subjects with high-normal BP and hyperten-
sives (CBP above the 90th percentile) are presented as one
group (hypertensive group: n ? 32, mean age 13 ? 2.8
[SD] years, 21 boys) and normotensives as a comparison
group (normotensive group: n ? 23, mean age 11.4 ? 2.6
years, 12 boys). According to United States Centers for
Disease Control and Prevention growth charts,1229 sub-
jects (12/17, normotensive/hypertensive) were obese
(?95th percentile for age and sex), 11 (6/5) overweight
(85th to 95th percentile), and 15 (5/10) were normal
weight (?85th percentile).
The average number of obtained HBP readings was
22.5 ? 2.2 (mean ? SD) per participant (range 12 to 24
readings). Sixty percent of recruited subjects performed all
the expected HBP readings, 30% performed 80% to 95%,
and 7% provided 50% to 80% of the expected readings.
Two subjects (3.5%) performed fewer than 12 HBP read-
ings and were excluded from the analysis. Comparison of
HBP values stored in the memory of the devices with
those reported by subjects showed small differences, prob-
ably attributed to copying errors. It should be noted that
participants were aware of the storage capacity of the HBP
monitors. Thus, misreporting of HBP values was pre-
vented in this study. In 10 children with small arms, who
was used the Omron 711 device (which has no storage
capacity), checking for misreporting was not possible.
However, in these young children, the HBP values were
filled in the forms by their parents. The average difference
between parallel test measurements using the HBP moni-
toring devices against a mercury column was ?3.6 ? 5.1
(SD) mm Hg. Fifteen percent of the subjects had a ?5 mm
Hg difference in diastolic BP between the HBP monitor
and the mercury manometer and 20% had a difference of
?10 mm Hg systolic BP. A total of 85 ? 8.7 readings
were obtained during the 24-h ABP monitoring. A fraction
of 20% ? 8% of readings were discarded and 3.9% ?
3.6% of time points were not represented in the ABP
profile, because both the initial and the automatically
repeated reading 2 min later were considered erroneous.
The average CBP of all three study visits did not differ
from the average CBP of visits 2 to 3 for the total group of
subjects as well as for hypertensives and normotensives
analyzed separately. Likewise, the average HBP of all 6
days did not differ from the average obtained after dis-
carding measurements of the initial day and no differences
in average HBP were found among days 1 to 6 (Fig. 1).
This was also the case for hypertensive subjects analyzed
separately. The initial reading of all morning and after-
noon HBP measurements was consistently higher than the
repeated one taken 1 min later (average BP decline 2.6 ?
1.2/2.1 ? 1.3 mm Hg for systolic/diastolic HBP; statisti-
cally significant in most of the days; Fig. 2). For each
monitoring day the average morning HBPs did not differ
from those taken in the afternoon.
The average CBP, HBP, and ABP levels of all study
participants and separately of hypertensive and normoten-
sive subjects are presented in Table 1 and Fig. 3. Signif-
icant correlations were observed between CBP and HBP
measurements (correlation coefficient r ? 0.73/0.57 for
systolic/diastolic BP), between CBP and 24-h ABP (r ?
0.59/0.49), and between HBP and 24-h ABP (r ? 0.72/
0.66) (P ? .001 for all measurements). The prediction
error for the HBP/CBP difference was 7% ? 6% for
systolic and 4% ? 11% for diastolic BP, for the HBP/ABP
difference 11% ? 5% and 4% ? 8%, and for the ABP/
CBP difference 4% ? 8% and 9% ? 11%. Hypertensive
subjects had higher CBP, HBP, and ABP values than
normotensives (Table 1). In normotensive subjects, sys-
FIG. 1. Average home systolic (circles) and diastolic (diamonds)
blood pressure of days 1 to 6 in normotensive (open symbols) and
hypertensive (black symbols) children and adolescents. Error
bars indicate standard deviation.
AJH–October 2004–VOL. 17, NO. 10 HOME BLOOD PRESSURE IN CHILDREN
tolic and diastolic CBP and heart rate were lower com-
pared to the corresponding values of daytime ABP
monitoring, whereas these differences were not observed
in hypertensive subjects (Fig. 3). In both normotensives
and hypertensives, there was a large difference in systolic
BP between HBP and daytime ABP measurements (?12
mm Hg), whereas this difference was smaller for diastolic
BP (?5 mm Hg) and heart rate. The HBP was lower than
CBP in hypertensives and to a lesser degree in normoten-
sives for systolic but not for diastolic BP. Nighttime ABP
and heart rate were lower than the daytime ABP, HBP, and
CBP in both normotensives and hypertensives. The only
exception was the absence of a difference between systolic
nighttime ABP and HBP in both normotensives and hy-
Clinic, home, and ambulatory systolic but not diastolic
BP was lower in children (?13 years; n ? 31) compared
with adolescents (n ? 24). Systolic HBP was lower than
awake ABP in both children (mean difference 14.6 ? 6.2
mm Hg, P ? .001) and adolescents (mean difference 13.1
? 7.3 mm Hg, P ? .001). There was a tendency for the
diastolic HBP to be lower than the awake ABP (by 3 mm
Hg on average) in both children and adolescents, but none
of these differences was statistically significant. No corre-
lation was found between age and the HBP–ABP differ-
ence (r ? 0.1 for both systolic and diastolic BP).
Of the 32 participants classified as hypertensives on the
basis of CBP measurements, hypertension was confirmed
by 24-h ABP monitoring in 15, whereas the other 17
subjects had normal 24-h ABP (white coat hypertensives).
Furthermore, of the 23 participants classified as normo-
tensives on the basis of CBP measurements, 16 were
normal and 7 had elevated 24-h ABP (masked hyperten-
To our knowledge, this is the first study to report HBP
values in normotensive and hypertensive children and
adolescents. The design of the study allows for the com-
parison of HBP with ABP and CBP in normotensive and
hypertensive children and adolescents. The main finding is
that, in contrast to what is known for adults, in children
and adolescents HBP is significantly lower than daytime
The CBP in this study was measured using conven-
Day 1Day 2 Day 3Day 4 Day 5Day 6
Systolic BP (mmHg)
114.9113.8 113.3 113.7114.3113.1
* * ** * *
Day 1Day 2Day 3 Day 4 Day 5Day 6
Diastolic BP (mmHg)
1st morning BP
2nd morning BP
1st afternoon BP
2nd afternoon BP
* * ******
FIG. 2. Average morning and afternoon home systolic (upper
panel) and diastolic (lower panel) blood pressure (BP). Numbers
in boxes represent average BP of each day. *P ? .05 for difference
from the initial measurement taken 1 min earlier.
normotensives analyzed separately (mm Hg ? SD)
Clinic, home, and ambulatory blood pressure in all study participants and in hypertensives and
(N ? 32)
(N ? 23)All (N ? 55)
Systolic blood pressure
Diastolic blood pressure
130.8 ? 7.6
118.9 ? 6.3
112.8 ? 8‡
106.7 ? 8.4‡
123.3 ? 11.8
113.8 ? 9.4
130.8 ? 8.1
115.4 ? 7.8
124.9 ? 7.3
123.9 ? 7.2†
107.0 ? 6.8‡
117.3 ? 6.3‡
127.9 ? 8.4
111.9 ? 8.5
121.7 ? 7.9
72.5 ? 8.1
73.7 ? 6.7
63.1 ? 6.3‡
67.2 ? 5.2‡
68.6 ? 8.7
70.9 ? 6.9
75.5 ? 8.3
61.4 ? 6.8
70 ? 7.7
72 ? 4.3*
57.6 ? 4.2*
66.2 ? 3.7*
74 ? 7.0
59.8 ? 6.1
68.4 ? 6.5
* P ? .05; † P ? .01; ‡ P ? .001 for difference from hypertensives.
AJH–October 2004–VOL. 17, NO. 10 HOME BLOOD PRESSURE IN CHILDREN
tional stethoscopic technique and a standard mercury
sphygmomanometer, as is usually the case for clinic mea-
surements by the physicians in practice.10On the other
hand, out-of-office BP measurements (HBP and ABP)
were measured using validated oscillometric devices,
which are widely used in general practice and are recom-
mended by official guidelines.4,8Parallel test measure-
ments of HBP monitoring devices against a mercury
column revealed reassuring results with a difference in
measured BP within the requirements of the Association
for the Advancement of Medical Instrumentation protocol
for device validation (mean difference ?5 ? 8 mm Hg).13
The compliance of study participants with HBP monitor-
ing was excellent, probably because home monitoring was
performed under the close supervision of the participants’
parents and, in the younger children, measurements were
taken by their parents.
Multiple CBP and HBP measurements were obtained to
allow for a progressive decline of BP,10which is known to
occur with repeated measurements. Because the initial
clinic visit and the initial home monitoring day have been
shown to provide higher and unstable values, several in-
vestigators prefer to discard these measurements.14–16In-
terestingly, in this study, the exclusion of the initial clinic
visit or the initial home monitoring day had little effect on
average CBP or HBP. Nevertheless, these data underline
the importance of multiple BP measurements on repeated
visits,10given that 42% of the children and the adolescents
referred for elevated BP were classified as normotensives.
As is the case for adults,16HBP showed a similar behavior
to CBP, given that the initial HBP reading was consis-
tently higher than the repeated one, even after several
monitoring days (Fig. 2). In addition, although this is a
small study group, it confirms previous reports showing
that systolic hypertension is more common than diastolic
hypertension among children and adolescents.17,18
Studies in normotensive adults showed little difference
between CBP and ABP, whereas in hypertensives, CBP is
known to be higher than ABP, reflecting the “clinic reac-
tion.”19In contrast to the findings in adults, accumulating
data suggest that in normotensive children and adolescents
the ABP is by about 10 mm Hg higher than CBP.20–23
This difference, also confirmed by the findings of the
present study (Fig. 3), has been attributed to the higher
level of physical activity during daytime in the young
population.20However, in the hypertensive group of the
present study, the difference between CBP and daytime
ABP was eliminated. This difference between the two
groups might be attributed to the presence of the white
coat effect, which is known to increase CBP, especially in
subjects with elevated pressures and not in normoten-
sives.24–26Thus, BPs measured by all methods were
higher in the hypertensive group, but the increase in CBP
was greater due to the white coat reaction, resulting in the
elimination of the difference between CBP and daytime
ABP in this group (Fig. 3). Previous studies in hyperten-
sive children showed contradictory findings (CBP was
lower21or exceeded daytime ABP.24,27
SYSTOLIC BP DIASTOLIC BPPULSE RATE
FIG. 3. Average clinic (C), home (H), and daytime ambulatory (A) blood pressure (BP) and pulse rate in normotensive (gray columns) and
hypertensive (black columns) children and adolescents. *P ? .05; **P ? .01; ***P ? .001 for differences between BP measurement
methods. b.p.m. ? beats per minute; NS ? nonsignificant.
AJH–October 2004–VOL. 17, NO. 10HOME BLOOD PRESSURE IN CHILDREN
With regard to HBP, studies in adults showed lower
values than for CBP and close to the levels of daytime
ABP.15,28This study showed that, in both normotensive
and hypertensive children and adolescents, systolic HBP is
lower than both daytime ABP and CBP and close to the
levels of nighttime ABP (Fig. 3). As is the case in adults,
the CBP–HBP difference was more pronounced in the
hypertensive group, reflecting the clinic reaction.19Dia-
stolic BP did not show the typical white coat effect, with
CBP being lower than HBP and with daytime ABP, pro-
viding the highest BP values (differences reaching statis-
tical significance only in the normotensive group). Studies
in adults also showed that systolic BP is responsible for
the majority of cases with a large difference between CBP
and ABP (white coat effect).29In addition, systolic BP
elevation is more common than diastolic BP in children
and adolescents.17,18Interestingly, in regard to pulse rate,
the pattern of comparisons of BP values obtained by the
different methods appear to be similar to systolic rather
than diastolic BP (HBP measurements being lower than
both CBP and ABP measurements; Fig. 3). These data
may indicate that, in both normotensive and hypertensive
children and adolescents, the sympathetic nervous system
activation (which can be grossly estimated by pulse rate
measurement) is a more important mechanism for the
regulation of systolic BP rather than diastolic BP.
This study has several limitations regarding the meth-
odology for BP measurement and the selection criteria for
study participants. First, differences in technologies for BP
measurement may be responsible, at least in part, for the
observed differences in BP obtained by the three methods.
Second, an important selection bias due to the inclusion of
children referred for elevated BP cannot be excluded,
because these children may have increased reactivity.
Third, age and BP values might influence the differences
in BP obtained when using different methods (auscultatory
or oscillometric) and devices. Although in this study,
comparison of BP values obtained using the different
methods showed a similar pattern in boys and girls and in
children and adolescents, a larger study sample, represen-
tative of the pediatric population stratified by age and sex
is needed to confirm these preliminary findings. Finally, it
should be mentioned that because of the lack of normative
values for CBP and ABP in Greek children, diagnosis of
hypertension in this study was based on other population
The important message from these preliminary data is
that, in children and adolescents, caution is needed in the
interpretation of out-of-clinic BP measurements obtained
using home monitoring. These data suggest that in this
population HBP values are significantly lower than both
clinic and ambulatory measurements. Until normative data
for HBP become available, decisions for diagnosis and
treatment of hypertension in children and adolescents
should not be based on such measurements. Large trials
relating HBP values with hypertensive target organ dam-
age are needed to estimate diagnostic thresholds for this
method in children and adolescents.
We thank G. Leoussis SA, Athens, Greece, for providing
five Omron HEM 705CP, five Omron IC, and two Omron
711 IS devices and for technical support and regular
calibration of these devices throughout the study.
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AJH–October 2004–VOL. 17, NO. 10 HOME BLOOD PRESSURE IN CHILDREN