Skip to main content
PMC home page
Annals of Pediatric Cardiology logoLink to Annals of Pediatric Cardiology
. 2019 May-Aug;12(2):90–96. doi: 10.4103/apc.APC_13_18

Prevalence of hypertension and prehypertension in schoolchildren from Central India

Ashish Patel 1, Anil Bharani 1,✉, Meenakshi Sharma 1, Anuradha Bhagwat 2, Neepa Ganguli 2, Dharampal Singh Chouhan 3
PMCID: PMC6521652  PMID: 31143032

Abstract

Background:

Epidemiological transition with increasing burden of cardiovascular risk factors is evident not only in adults but also in children. The data on the prevalence of prehypertension and hypertension in children show large regional differences in India and such data are not available from Central India. We, therefore, conducted a large cross-sectional study in Indore to determine the distribution of blood pressure (BP) and the prevalence of hypertension and prehypertension among schoolchildren.

Methods:

A total of 11,312 children (5305 girls, 6007 boys) aged 5–15 years, drawn from 80 government and private schools in equal proportion, were evaluated. Anthropometric measurements were obtained and BPs were measured using The Fourth Report on The Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents as reference standard. BP ≥90th to <95th percentile for given percentile of height was considered as prehypertension, whereas any BP ≥95th percentile was defined as hypertension. Multiple linear regression analysis was used to find out the determinants of hypertension in these children.

Results:

Prehypertension was detected in 6.9% and 6.5% and hypertension was found in 6.8% and 7.0% of boys and girls, respectively. Height and weight were found to be a significant predictor of systolic and diastolic BP among both boys and girls.

Conclusions:

Our results show a high prevalence of prehypertension and hypertension in Indore schoolchildren with age and height being significant determinants. This highlights the need for routine BP measurements in children by pediatricians when they treat them for intercurrent illnesses or vaccinate them. It should also be mandatory as a part of school health checkup programs to detect childhood hypertension for further counseling and therapy.

Keywords: Blood pressure, pediatric hypertension, school health checkup

INTRODUCTION

It has been shown that even a slight elevation of blood pressure (BP) in childhood is likely to elevate the risk of hypertension by several folds in adult population.[1,2,3,4] Epidemiological transition with increasing burden of cardiovascular risk factors such as obesity and hypertension is already evident not only in adult population but also in pediatric population in developing countries including India.[5,6,7,8,9,10,11] The survey data show large variation in the prevalence of prehypertension and hypertension among the children from various part of India.[3,5,6] Further, large studies on the prevalence of pediatric hypertension from Central India are lacking.

The present study was conducted as part of the Indian Council of Medical Research (ICMR) Jai Vigyan Mission mode project on “Community Control of Rheumatic Fever/Rheumatic Heart Disease” (2007–2014). Our primary aim was to know about the distribution of BP in schoolchildren aged 5–15 years and secondarily to find out the prevalence of prehypertension and hypertension among them. The Fourth Report on The Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents was used as reference standard.[12]

METHODS

Study sample

The sample size was calculated using the formula from the WHO STEPwise approach to chronic disease surveillance (N = Z2 × P [1-P]/e2),[13] where N = sample size, Z = level of confidence, P = baseline level of the selected indicator, and e = margin of error. P was estimated at 0.50 (recommended by the STEPS survey guidelines when the estimated baseline is unknown), Z = 1.96 (at 95% confidence interval), and e = 0.05; thus, the estimated sample size was n = 1.962 × 0.5 (1–0.5)/0.052 = 384. This basic sample size was adjusted for design effect for age–sex estimates, 5–15 years’ age range (1-year intervals), and the required sample size was, therefore, n = 384 × 2× 11 = 8448.

We studied a total of 11,312 children (5305 girls, 6007 boys) from 80 schools located in 43 out of total 69 municipal wards of Indore. Schools were selected to represent students attending government schools and private schools in equal proportions. The protocol was approved by the Institutional Ethics and Scientific Committee.

Blood pressure measurement

The mercury BP instrument used in our study was new leak proof and their accuracy was checked with standard mercury manometer (Baumanometer, W. A. BAUM Co., Inc., New York, USA) kept for calibration purposes.

The children were evaluated by a team consisting of two specially trained pediatricians, two research assistants, and a social worker who visited the school at least a week before the examination date. The preexamination visit was intended to familiarize with the teachers and students and to discuss and schedule the plan of examination.

All children were clinically examined in a comfortable position in a noise-free room during morning hours. Weight was measured using a calibrated scale and height using a stadiometer. BP measurement was carried out using mercury sphygmomanometer, following standard guidelines in sitting position. At least 5 min of rest in sitting position was provided before taking BP. Children were asked to sit on appropriate sized chairs, allowing for comfortable sitting with back supported, legs uncrossed and touching the ground, and arm supported during measurements. Observers and children were instructed to keep silence. The right arm was selected for BP measurement for consistency. Appropriate BP cuff was selected covering at least 40% of arm circumference with midline of cuff positioned over the arm following palpation of the brachial artery in the antecubital fossa. BP was measured in each child three times at a minimum interval of at least 5 min in between successive measurements on the same day. The onset of the first Korotkoff sound was taken as systolic BP (SBP) and end of Korotkoff sounds as diastolic BP.[14] In circumstances where Korotkoff sounds were heard till 0 mmHg, the BP measurement was repeated with less pressure on the head of the stethoscope. In the event of persistence of very low fifth Korotkoff sounds, fourth Korotkoff sounds (muffling of the sounds) were recorded as the diastolic BP.[14,15,16]

Statistical method

First readings of both SBP and diastolic BP were discarded to lessen the effect of anxiety on BP. A mean of the second and third values, for both SBP and diastolic BP, was computed and taken as BP of the child and used for further analysis. Body mass index (BMI) was calculated based on height and weight data for every child in the entire cohort [Table 1]. Data from The Fourth Report on The Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents were considered as reference value for defining prehypertension and hypertension.[12]

Table 1.

Distribution of anthropometric variables according to age and gender

Age (Years) Girls Boys
n Height Mean±SD Weight Mean±SD BMI Mean±SD n Height Mean±SD Weight Mean±SD BMI Mean±SD
5 486 106.94±6.48 15.39±3.04 13.46±2.63 364 107.99±5.89 15.06±2.45 12.87±1.39
6 498 111.5±6.5 16.73±3.52 13.4±2.22 599 112.77±6.82 16.91±4.09 13.25±3.15
7 492 116.49±6.76 17.96±3.37 13.31±2.85 706 117.88±7 18.74±3.83 13.38±1.72
8 762 122.47±6.54 20.66±4.86 13.66±2.39 892 122.9±7.15 20.67±4.39 13.57±1.89
9 644 127.33±7.01 22.62±5.17 13.84±2.33 652 128.91±6.93 23.66±5.48 14.1±2.2
10 554 132.36±8.56 25.51±6.96 14.38±2.73 644 132.75±7.6 25.12±6.15 14.13±2.69
11 490 137.16±8.5 27.72±7.42 14.55±2.61 531 136.73±7.67 27.23±6.35 14.44±2.32
12 476 140.95±7.6 30.05±6.88 15.01±2.69 502 140.9±8.15 29.23±7.12 14.6±2.67
13 400 147.03±7.12 34.89±7.05 16.05±2.55 457 147.49±8.5 33.38±7.96 15.18±2.44
14 347 150.05±7.51 38.81±7.72 17.17±2.77 390 153.44±9.49 37.98±9.5 15.96±2.81
15 156 150.49±6.66 40.46±9.01 17.79±3.36 270 158.66±8.11 42.71±9.99 16.84±3.11
Total 5305 128.58±15.29 24.64±9.31 14.41±2.86 6007 130.29±15.84 24.91±9.45 14.18±2.59
Open in a new tab

SD- standard deviation; BMI - Body mass index

BP ≥90th to <95th percentile was considered as prehypertension, and BP ≥95th percentile was considered as systemic hypertension. Further, hypertension was classified as Stage I (≥95th to ≤99th percentile plus 5 mmHg) and Stage II (>99th percentile plus 5 mmHg). We added 5 mm to observed ≥95th and ≥99th-percentile values to define Stage I and Stage II hypertension more clearly since the difference between the 95th and 99th percentiles is only 5–10 mmHg which is not large enough. Further, children were considered to have prehypertension if they were found to have SBP >120 mmHg and/or diastolic BP >80 mmHg, even if this value is <90th percentile of BP for each year of age group.[12]

Multiple linear regression with stepwise forward elimination was used to assess the determinants of SBP and diastolic BP in the reference sample. Separate analyses were performed for sex, SBP, and diastolic BP. The results suggested that age and height were the principle determinants of SBP and height was the principle determinants of diastolic BP in our study sample. To evaluate BP levels at specific height percentiles for 1-year age groups, we first converted height percentiles to the z-score scale.

We then regressed BP on height for each 1 year for male and female groups. Separate analyses were performed for SBP and diastolic BP thus:

  • SBP(age) =α1+ β1 (z height) + e1 (Equation 1)

  • Diastolic BP(age) = α2+ β2 (z height) + e2 (Equation 2).

As the third step, we estimated the 95th and 90th percentiles for BP at specific height percentiles for each 1-year sex-pooled group. For instance, the 95th percentile of SBP for a child with height corresponding to the 90th percentile for the age group was estimated thus:

95th percentile of SBP (for age-specific 90th percentile of height) = α1+ β1 (1.28) +1.645 σ

where σ2 was estimated from the residual mean square from the regression model represented by Equation 1.

The corresponding 90th percentile of SBP for the child would be:

90th percentile of SBP (for age-specific 90th percentile of height) = α1+ β1 (1.28) +1.28 σ.

Similarly, percentile of diastolic BP was calculated using the regression model in Equation (2). All statistical analyses were performed using the SPSS 23 version (IBM Corp, USA) and Microsoft Excel (Microsoft Corp, USA).

RESULTS

Age- and gender-specific distributions of anthropometric variables (weight, height, and BMI) in the study group are shown in Table 1. The age-specific BP distribution for boys and girls based on height percentile is shown in Tables 2 and 3. Cutoff values of height percentiles can be found in supplementary appendix [Supplementary Table 1].

Table 2.

Blood pressure levels for boys by age and height percentiles

Age BP Percentile ↓ Systolic BP (mmHg)
← Percentile of Height →		 Diastolic BP (mmHg)
← Percentile of Height →
5th 10th 25th 50th 75th 90th 95th 5th 10th 25th 50th 75th 90th 95th
5 50th 95 96 96 96 96 97 97 44 45 45 46 46 47 47
90th 105 106 106 106 106 107 107 54 54 55 55 56 56 56
95th 108 108 109 109 109 109 110 56 57 57 58 58 59 59
99th 114 114 114 114 115 115 115 61 62 62 63 63 64 64
6 50th 94 95 96 96 97 98 98 49 49 50 50 50 51 51
90th 105 106 106 107 108 108 109 62 62 62 62 63 63 63
95th 108 109 109 110 111 111 112 65 65 66 66 66 67 67
99th 114 114 115 116 117 117 118 72 72 72 73 73 73 73
7 50th 95 95 96 98 99 100 101 49 49 50 51 51 52 52
90th 106 107 108 109 111 112 112 62 62 63 64 64 65 66
95th 110 110 111 113 114 115 116 66 66 67 67 68 69 69
99th 116 117 118 119 120 121 122 73 73 74 74 75 76 76
8 50th 95 96 98 99 101 102 103 49 50 51 52 53 54 55
90th 106 107 109 110 112 113 114 63 63 64 65 67 68 68
95th 110 110 112 113 115 116 117 66 67 68 69 70 72 72
99th 116 116 118 119 121 122 123 74 74 75 77 78 79 79
9 50th 98 99 100 101 103 104 105 49 50 51 53 55 57 58
90th 110 111 112 113 115 116 117 63 64 66 68 70 72 73
95th 113 114 115 117 118 119 120 68 69 71 72 74 76 77
99th 120 121 122 123 125 126 127 76 77 78 80 82 84 85
10 50th 98 99 101 103 104 106 107 52 52 53 54 56 57 57
90th 110 111 113 114 116 118 119 67 67 68 69 71 72 72
95th 114 115 116 118 120 121 122 71 72 73 74 75 76 76
99th 120 121 122 124 126 127 128 79 79 81 82 83 84 84
11 50th 99 100 102 103 104 106 107 52 53 54 56 57 58 59
90th 110 111 112 114 115 116 117 67 68 69 71 72 73 74
95th 113 114 115 117 118 119 120 72 72 74 75 76 78 78
99th 119 119 121 122 124 125 126 80 81 82 83 85 86 87
12 50th 101 102 102 103 104 104 105 52 53 54 56 57 59 60
90th 113 113 114 115 115 116 116 67 68 69 71 72 74 75
95th 116 117 117 118 119 119 120 71 72 73 75 77 78 79
99th 123 123 124 124 125 126 126 79 80 81 83 85 86 87
13 50th 101 102 103 104 106 107 107 53 53 55 56 57 59 59
90th 112 113 114 115 116 118 118 68 68 70 71 72 74 74
95th 115 116 117 118 120 121 121 72 73 74 75 77 78 79
99th 121 122 123 124 125 127 127 80 81 82 83 85 86 87
14 50th 107 107 108 108 109 110 110 54 55 57 59 61 63 64
90th 118 119 119 120 121 122 122 68 69 71 73 75 77 78
95th 121 122 123 123 124 125 125 72 73 75 77 79 81 82
99th 128 128 129 130 130 131 131 80 81 83 85 87 89 90
15 50th 106 106 107 107 107 108 108 56 57 59 61 63 65 66
90th 119 119 119 120 120 120 121 70 71 73 75 77 78 80
95th 122 122 123 123 124 124 124 73 75 76 78 80 82 83
99th 129 129 129 130 130 131 131 81 82 83 85 88 89 90
Open in a new tab

Table 3.

Blood pressure levels for girls by age and height percentiles

Age BP Percentile ↓ Systolic BP (mmHg)
← Percentile of Height →		 Diastolic BP (mmHg)
← Percentile of Height →
5th 10th 25th 50th 75th 90th 95th 5th 10th 25th 50th 75th 90th 95th
5 50th 93 94 94 95 96 97 97 48 48 49 49 50 51 51
90th 103 104 104 105 106 107 107 60 60 60 61 62 62 63
95th 106 106 107 108 109 110 110 63 63 64 64 65 66 66
99th 111 112 113 113 114 115 115 69 69 70 71 71 72 72
6 50th 93 94 94 95 96 97 97 51 51 51 52 52 53 53
90th 105 105 106 107 107 108 108 63 63 63 63 64 64 64
95th 108 108 109 110 111 111 112 66 66 66 67 67 67 68
99th 114 115 115 116 117 117 118 72 72 73 73 73 74 74
7 50th 94 94 95 96 96 97 98 53 53 54 54 54 54 54
90th 103 104 105 105 106 107 107 65 65 65 65 65 65 66
95th 106 107 107 108 109 109 110 68 68 68 68 69 69 69
99th 111 112 112 113 114 115 115 74 74 74 75 75 75 75
8 50th 95 96 97 99 100 102 102 53 54 54 55 56 56 57
90th 107 107 109 110 111 113 113 66 67 67 68 69 69 69
95th 110 110 112 113 115 116 117 70 70 71 72 72 73 73
99th 116 116 118 119 121 122 123 77 77 78 78 79 80 80
9 50th 97 98 100 101 103 104 105 54 55 56 56 57 58 58
90th 109 110 111 113 115 116 117 68 69 69 70 71 71 72
95th 112 113 115 116 118 119 120 72 73 73 74 75 75 76
99th 119 119 121 122 124 126 126 80 80 81 81 82 83 83
10 50th 98 99 101 103 105 107 108 56 57 58 58 59 60 61
90th 110 111 113 115 117 119 120 70 70 71 72 73 74 75
95th 114 115 117 119 121 123 124 74 74 75 76 77 78 79
99th 121 122 123 125 127 129 130 81 82 83 84 85 86 86
11 50th 98 100 102 104 106 108 110 58 59 60 61 62 63 64
90th 111 112 114 116 119 121 122 72 73 74 75 76 77 77
95th 114 115 118 120 122 124 125 76 76 77 78 80 80 81
99th 121 122 124 126 129 131 132 83 84 85 86 87 88 88
12 50th 100 101 102 104 106 108 109 62 62 62 63 63 63 63
90th 111 112 114 116 118 120 121 76 76 76 76 77 77 77
95th 115 116 118 120 121 123 124 80 80 80 80 81 81 81
99th 121 122 124 126 128 130 131 87 87 88 88 88 88 88
13 50th 105 105 106 107 107 108 108 61 61 61 61 61 61 61
90th 117 117 118 118 119 120 120 74 75 75 75 75 75 75
95th 120 120 121 122 122 123 123 78 78 78 79 79 79 79
99th 126 127 127 128 129 129 130 86 86 86 86 86 86 86
14 50th 109 110 110 110 111 111 111 65 65 65 65 65 65 65
90th 123 123 123 124 124 125 125 79 79 79 79 79 79 79
95th 127 127 127 128 128 128 129 83 83 83 83 83 83 83
99th 134 134 134 135 135 136 136 90 90 91 91 91 91 91
15 50th 107 108 109 110 111 112 112 64 64 65 65 65 65 66
90th 120 121 122 123 124 125 126 78 78 79 79 79 79 80
95th 124 125 126 127 128 129 129 82 82 83 83 83 83 83
99th 131 132 133 134 135 136 136 90 90 90 90 91 91 91
Open in a new tab

Supplementary Table 1.

Height percentile by age and sex

Sex Age Height percentiles
5 10 25 50 75 90 95
Girls 5 96.35 99 103 107 110 115 118
6 101 103.9 107 111 116 119.1 121
7 105 107.3 112 117 121 125 128
8 112.15 115 118 122 126 131 134
9 116 119 122 127 132 136 138
10 120 122 127 132 137 144 148
11 124 127 131 136.5 142.25 148.9 152
12 128 130 136 141 146 150 153.15
13 134.05 138 143 148 152 155 158
14 138 142 146 150 155 160 162
15 139.85 142.7 146 150 155 159 163
Boys 5 98 101 104 108 112 115 117
6 101 104 109 113 118 121 123
7 105.35 109 113.75 118 122 126.3 129
8 112 114 118 123 127 132 135
9 119 121 124 128 133.75 138 141
10 121 123 127 132 137 142.5 145
11 125 128 131 136 141 147 151
12 129 131 135 140 146 151 155
13 135 137 141 147 153 159 162
14 140 142 147 153 160 166.9 171
15 144 149 154 159 164 170 172
Open in a new tab

Data from The Fourth Report on The Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents were considered as reference value for defining target BP, prehypertension, and hypertension. Prehypertension was detected in 6.9% and 6.5% of boys and girls, respectively, whereas hypertension was found in 6.8% (Stage I: 6.7%; Stage II: 0.1%) of boys and 7.0% (Stage I: 6.6%; Stage II: 0.3%) of girls [Table 4].

Table 4.

Prevalence of Prehypertension and Hypertension in Study Cohort

Age (Years) Normal (%) Pre-HTN (%) HTN Stage I (%) HTN Stage II (%) Total
Boys Girls Boys Girls Boys Girls Boys Girls Boys Girls
5 310 (85.2) 414 (85.2) 24 (6.6) 41 (8.4) 30 (8.2) 31 (6.4) 0 (0) 0 (0) 364 486
6 502 (83.8) 413 (82.9) 51 (8.5) 37 (7.4) 46 (7.7) 43 (8.6) 0 (0) 5 (1) 599 498
7 619 (87.7) 422 (85.8) 17 (2.4) 19 (3.9) 70 (9.9) 45 (9.1) 0 (0) 6 (1.2) 706 492
8 755 (84.6) 631 (82.8) 86 (9.6) 67 (8.8) 50 (5.6) 61 (8) 1 (0.1) 3 (0.4) 892 762
9 593 (91) 564 (87.6) 30 (4.6) 50 (7.8) 29 (4.4) 30 (4.7) 0 (0) 0 (0) 652 644
10 555 (86.2) 511 (92.2) 50 (7.8) 3 (0.5) 37 (5.7) 40 (7.2) 2 (0.3) 0 (0) 644 554
11 441 (83.1) 442 (90.2) 59 (11.1) 41 (8.4) 31 (5.8) 7 (1.4) 0 (0) 0 (0) 531 490
12 444 (88.4) 423 (88.9) 22 (4.4) 38 (8) 36 (7.2) 15 (3.2) 0 (0) 0 (0) 502 476
13 387 (84.7) 352 (88) 33 (7.2) 9 (2.3) 37 (8.1) 39 (9.8) 0 (0) 0 (0) 457 400
14 334 (85.6) 279 (80.4) 38 (9.7) 40 (11.5) 18 (4.6) 28 (8.1) 0 (0) 0 (0) 390 347
15 251 (93) 145 (92.9) 2 (0.7) 0 (0) 16 (5.9) 11 (7.1) 1 (0.4) 0 (0) 270 156
Total 5191 (86.4) 4596 (86.6) 412 (6.9) 345 (6.5) 400 (6.7) 350 (6.6) 4 (0.1) 14 (0.3) 6007 5305
Open in a new tab

On regression analysis, age and height were the principle determinants of SBP and height was the principle determinants of diastolic BP in our study sample. Age- and sex-specific regression coefficients are presented in Table 5.

Table 5.

Age and Sex Specific Regression Coefficients

BP Age Boys Girls
α β σ α β σ
SBP 5 96.107 0.427 7.8013 95.289 1.189 7.73706
6 96.222 1.076 8.4053 95.246 1.136 8.89119
7 97.711 1.88 9.0975 95.716 1.113 7.51115
8 99.174 2.362 8.6768 98.905 2.12 8.66965
9 101.383 2.048 9.3547 101.302 2.411 9.0966
10 102.635 2.55 9.217 102.755 2.957 9.70966
11 103.027 2.195 8.2156 104.12 3.417 9.5618
12 103.16 1.017 9.0397 104.334 2.882 9.2577
13 104.198 1.956 8.5123 106.669 1.072 9.10832
14 108.384 1.139 9.1082 110.378 0.575 10.47583
15 107.084 0.601 9.7719 109.912 1.568 10.27855
DBP 5 45.68 0.759 7.3085 49.453 0.94 9.0881
6 49.892 0.477 9.7566 51.855 0.545 9.05599
7 50.515 1.144 10.2566 53.728 0.196 8.94799
8 51.819 1.738 10.63 54.838 1.015 10.14509
9 53.339 2.92 11.6285 56.286 1.091 10.75889
10 54.481 1.691 11.6638 58.493 1.469 10.7973
11 55.52 2.062 11.877 61.06 1.561 10.5766
12 55.696 2.494 11.77269 62.54 0.38 10.8303
13 56.002 1.992 11.74261 61.175 0.16 10.5751
14 58.894 3.002 11.18293 65.135 0.153 10.95954
15 61.288 3.003 10.38971 64.847 0.418 10.91172
Open in a new tab

SBP- Systolic blood pressure; DBP - Diastolic blood pressure

DISCUSSION

Primary hypertension in children was once considered a rarity and has emerged as an important public health problem world over.[17] The prevalence of hypertension in children is high in India compared to developed countries like the USA where the prevalence of elevated BP was found to be 2.7%–3.7% in different population-based surveys.[18] Similarly, the prevalence of childhood hypertension has varied between different populations within India [Table 6].[6,19,20,21,22,23] We have shown the distribution of normal BP in a large cohort of children between ages of 5 and 15 years and the prevalence of prehypertension and hypertension among them from Indore district of Madhya Pradesh situated in Central India. Prehypertension was detected in 6.9% and 6.5% of boys and girls, respectively, whereas hypertension was found in 6.8% of boys and 7.0% of girls. With this prevalence, one out of every ten children would require some intervention to control hypertension, to reduce the risk associated with elevated BPs during childhood.[24,25] Chadha et al., in a sample of 10,215 schoolchildren from New Delhi, reported a much higher prevalence of hypertension (11.9% for boys and 11.4% for girls) which is not duplicated in other studies from Amritsar, Assam, Shimla, Surat, or by us at Indore.[6,20,21,22,23] Using similar cutoff criteria of hypertension, Borah et al. from Assam reported hypertension in 7.6% of schoolchildren with a higher prevalence among girls, similar to our findings.[6] Sharma et al. from Shimla reported a 5.9% prevalence of hypertension and 12.3% prevalence of prehypertension in school-going children aged 11–17 years.[22] However, for defining stages of hypertension, they did not add 5 mmHg to the 95th and 99th percentile values as adopted in The Fourth Report on The Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents.

Table 6.

Blood pressure prevalence from various parts of India

Ref. No. Authors Sample size D.B.P. Measurement B.P. Measurement B.P. definition Prehypertension Hypertension (%) Age group
Boys Girls Total Boys Girls Total
06 Borah et al. 10003 4th korotkoff Single day Reference no.12 Not reported 7.3 7.8 7.6 5-14 years
19 Krishna et al. 6320 Not defined Single day Reference no.12 Not available Not available 7-18 years
20 Prabhjot et al. 1000 Not defined Single day Reference no.15 Not reported 8.33 6.52 7.5 6-14 years
21 Buch et al. 1249 5th korotkoff Single day Reference no.12 Not reported 6.74 6.13 6.48 6-18 years
22 Sharma et al. 1085 5th korotkoff Single day Reference no.12 12.46 11.46 12.3 4.7 6.8 5.9 11-17 years
23 Chadha et al. 10215 5th korotkoff Single day Not reported 11.9 11.4 5-14 years
Open in a new tab

Differences in the prevalence of hypertension among these studies could partly be attributed to selection of different cutoff points for defining hypertension, age difference, differences in the study design, the number of visits made for measurement of BP, and method of averaging BP taken between different visits. For example, we have discarded the first BP readings to lessen the effect of anxiety and taken the average of the second and third BP readings in consideration, whereas Borah et al. have used a mean of three measurements of BP.[6]

We classified BP as normal, prehypertension, or hypertension based on a single BP reading on a planned school visit. Multiple studies have shown that repeated measurements on different occasions lead to a reduction in proportion of hypertensive patients.[10,26] However, multiple readings of BP taken on the same day were also considered appropriate in a series of epidemiological surveys.[27]

Children born to hypertensive parents are known to have a higher prevalence of hypertension. Further subclinical endothelial dysfunction has been reported in normotensive children of hypertensive parents.[28] There is a high prevalence of hypertension in India affecting one-fourth of adult population.[29] We have, however, not obtained a family history in our cohort and, therefore, do not know if parental hypertension in these children contributed to a higher prevalence of prehypertension and hypertension found in our study. Our study cohort had equal representation from relatively richer and economically deprived children; thus, any possible effect of socioeconomic status of the parents on BP is unlikely.[30,31,32,33] We have not performed detailed anthropometric measurements besides height, weight, and BMI and thus do not have information on the prevalence of central obesity in our study population that could have a bearing on observed BP. We have not evaluated the salt intake and other dietary habits and physical activities in our cohort. This could be considered in design of future studies specifically for the assessment of BP in children.

Despite these limitations, to conclude, there is a high prevalence of prehypertension and hypertension in our cohort. Thus, children should have BP recorded during school health checkups as a routine and further routine BP measurements should invariably be done when children come in medical contact for concurrent illnesses and for vaccination. Those who show elevated BPs should be counseled along with their parents and should be periodically followed by pediatricians and family practitioners for further therapy.

Financial support and sponsorship

This study was financially supported by ICMR, New Delhi, India.

Conflicts of interest

There are no conflicts of interest.

REFERENCES

  • 1.Chen X, Wang Y. Tracking of blood pressure from childhood to adulthood: A systematic review and meta-regression analysis. Circulation. 2008;117:3171–80. doi: 10.1161/CIRCULATIONAHA.107.730366. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 2.Kelly RK, Thomson R, Smith KJ, Dwyer T, Venn A, Magnussen CG, et al. Factors affecting tracking of blood pressure from childhood to adulthood: The childhood determinants of adult health study. J Pediatr. 2015;167:1422–800. doi: 10.1016/j.jpeds.2015.07.055. [DOI] [PubMed] [Google Scholar]
  • 3.Soudarssanane M, Mathanraj S, Sumanth M, Sahai A, Karthigeyan M. Tracking of blood pressure among adolescents and young adults in an urban slum of Puducherry. Indian J Community Med. 2008;33:107–12. doi: 10.4103/0970-0218.40879. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 4.Toschke AM, Kohl L, Mansmann U, von Kries R. Meta-analysis of blood pressure tracking from childhood to adulthood and implications for the design of intervention trials. Acta Paediatr. 2010;99:24–9. doi: 10.1111/j.1651-2227.2009.01544.x. [DOI] [PubMed] [Google Scholar]
  • 5.Rao S, Kanade A, Kelkar R. Blood pressure among overweight adolescents from urban school children in Pune, India. Eur J Clin Nutr. 2007;61:633–41. doi: 10.1038/sj.ejcn.1602555. [DOI] [PubMed] [Google Scholar]
  • 6.Borah PK, Devi U, Biswas D, Kalita HCh, Sharma M, Mahanta J, et al. Distribution of blood pressure and correlates of hypertension in school children aged 5-14 years from North East India. Indian J Med Res. 2015;142:293–300. doi: 10.4103/0971-5916.166591. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 7.Kearney PM, Whelton M, Reynolds K, Muntner P, Whelton PK, He J, et al. Global burden of hypertension: Analysis of worldwide data. Lancet. 2005;365:217–23. doi: 10.1016/S0140-6736(05)17741-1. [DOI] [PubMed] [Google Scholar]
  • 8.Goel M, Pal P, Agrawal A, Ashok C. Relationship of body mass index and other life style factors with hypertension in adolescents. Ann Pediatr Cardiol. 2016;9:29–34. doi: 10.4103/0974-2069.171393. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 9.Nur N, Cetinkaya S, Yilmaz A, Ayvaz A, Bulut MO, Sümer H, et al. Prevalence of hypertension among high school students in a middle anatolian province of Turkey. J Health Popul Nutr. 2008;26:88–94. [PMC free article] [PubMed] [Google Scholar]
  • 10.McNiece KL, Poffenbarger TS, Turner JL, Franco KD, Sorof JM, Portman RJ, et al. Prevalence of hypertension and pre-hypertension among adolescents. J Pediatr. 2007;150:640–4. doi: 10.1016/j.jpeds.2007.01.052. 644.e1. [DOI] [PubMed] [Google Scholar]
  • 11.Antal M, Regöly-Mérei A, Nagy K, Greiner E, Biró L, Domonkos A, et al. Representative study for the evaluation of age- and gender-specific anthropometric parameters and blood pressure in an adolescent hungarian population. Ann Nutr Metab. 2004;48:307–13. doi: 10.1159/000081197. [DOI] [PubMed] [Google Scholar]
  • 12.National High Blood Pressure Education Program Working Group on High Blood Pressure in Children and Adolescents. The fourth report on the diagnosis, evaluation, and treatment of high blood pressure in children and adolescents. Pediatrics. 2004;114:555–76. [PubMed] [Google Scholar]
  • 13.World Health Organization. WHO STEPS Surveillance Manual: The WHO STEPwise approach to chronic disease risk factor surveillance. Geneva, Switzerland: World Health Organization; 2005. [Google Scholar]
  • 14.Update on the 1987 task force report on high blood pressure in children and adolescents: A working group report from the national high blood pressure education program. National high blood pressure education program working group on hypertension control in children and adolescents. Pediatrics. 1996;98:649–58. [PubMed] [Google Scholar]
  • 15.Report of the Second Task Force on Blood Pressure Control in Children–1987. Task force on blood pressure control in children. National heart, lung, and blood institute, Bethesda, Maryland. Pediatrics. 1987;79:1–25. [PubMed] [Google Scholar]
  • 16.Londe S, Klitzner TS. Auscultatory blood pressure measurement – Effect of pressure on the head of the stethoscope. West J Med. 1984;141:193–5. [PMC free article] [PubMed] [Google Scholar]
  • 17.Flynn J. The changing face of pediatric hypertension in the era of the childhood obesity epidemic. Pediatr Nephrol. 2013;28:1059–66. doi: 10.1007/s00467-012-2344-0. [DOI] [PubMed] [Google Scholar]
  • 18.Din-Dzietham R, Liu Y, Bielo MV, Shamsa F. High blood pressure trends in children and adolescents in national surveys, 1963 to 2002. Circulation. 2007;116:1488–96. doi: 10.1161/CIRCULATIONAHA.106.683243. [DOI] [PubMed] [Google Scholar]
  • 19.Krishna P, Bajaj S, Thennarasu K, Desai N, PrasammaKumar KM. Regional differences in the reference blood pressure in young Indians. Indian Pediatr. 2007;44:921–3. [PubMed] [Google Scholar]
  • 20.Prabhjot A, Kaur N, Kumar K, Sighu S. Variation in blood pressure among school children in Amristar (Punjab) Anthropologist. 2005;7:201–4. [Google Scholar]
  • 21.Buch N, Goyal JP, Kumar N, Parmar I, Shah VB, Charan J, et al. Prevalence of hypertension in school going children of Surat city, Western India. J Cardiovasc Dis Res. 2011;2:228–32. doi: 10.4103/0975-3583.89807. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 22.Sharma A, Grover N, Kaushik S, Bhardwaj R, Sankhyan N. Prevalence of hypertension among schoolchildren in Shimla. Indian Pediatr. 2010;47:873–6. doi: 10.1007/s13312-010-0148-5. [DOI] [PubMed] [Google Scholar]
  • 23.Chadha SL, Tandon R, Shekhawat S, Gopinath N. An epidemiological study of blood pressure in school children (5-14 years) in Delhi. Indian Heart J. 1999;51:178–82. [PubMed] [Google Scholar]
  • 24.LaRosa C, Meyers K. Epidemiology of hypertension in children and adolescents. J Med Liban. 2010;58:132–6. [PubMed] [Google Scholar]
  • 25.Kollias A, Dafni M, Poulidakis E, Ntineri A, Stergiou GS. Out-of-office blood pressure and target organ damage in children and adolescents: A systematic review and meta-analysis. J Hypertens. 2014;32:2315–31. doi: 10.1097/HJH.0000000000000384. [DOI] [PubMed] [Google Scholar]
  • 26.Rames LK, Clarke WR, Connor WE, Reiter MA, Lauer RM. Normal blood pressure and the evaluation of sustained blood pressure elevation in childhood: The Muscatine study. Pediatrics. 1978;61:245–51. [PubMed] [Google Scholar]
  • 27.Centers for Disease Control and Prevention NHaNES. Physician Examination Procedures Manual. [Last accessed on 2017 Apr 12]. Available from: https://www.cdc.gov/nchs/data/nhanes/1999-2000/manuals/pe.pdf .
  • 28.Bharani A, Jain N, Jain A, Deedwania P. Endothelium-dependent vasodilation is impaired in healthy offspring of hypertensive parents. Indian Heart J. 2011;63:255–8. [PubMed] [Google Scholar]
  • 29.Anchala R, Kannuri NK, Pant H, Khan H, Franco OH, Di Angelantonio E, et al. Hypertension in India: A systematic review and meta-analysis of prevalence, awareness, and control of hypertension. J Hypertens. 2014;32:1170–7. doi: 10.1097/HJH.0000000000000146. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 30.Coto V, Lucariello A, Cocozza M, Oliviero U, Cacciatore L. Socioeconomic status and hypertension in children of two state schools in Naples, Italy: Preliminary findings. Eur J Epidemiol. 1987;3:288–94. doi: 10.1007/BF00149738. [DOI] [PubMed] [Google Scholar]
  • 31.Ip P, Ho FK, So HK, Chan DF, Ho M, Tso W, et al. Socioeconomic gradient in childhood obesity and hypertension: A multilevel population-based study in a Chinese community. PLoS One. 2016;11:e0156945. doi: 10.1371/journal.pone.0156945. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 32.Kivimäki M, Kinnunen ML, Pitkänen T, Vahtera J, Elovainio M, Pulkkinen L, et al. Contribution of early and adult factors to socioeconomic variation in blood pressure: Thirty-four-year follow-up study of school children. Psychosom Med. 2004;66:184–9. doi: 10.1097/01.psy.0000126821.33005.6b. [DOI] [PubMed] [Google Scholar]
  • 33.Kaczmarek M, Stawińska-Witoszyńska B, Krzyżaniak A, Krzywińska-Wiewiorowska M, Siwińska A. Who is at higher risk of hypertension? Socioeconomic status differences in blood pressure among Polish adolescents: A population-based ADOPOLNOR study. Eur J Pediatr. 2015;174:1461–73. doi: 10.1007/s00431-015-2554-0. [DOI] [PMC free article] [PubMed] [Google Scholar]

Articles from Annals of Pediatric Cardiology are provided here courtesy of Wolters Kluwer -- Medknow Publications

RESOURCES