Hannelore K. Neuhauser, Michael Thamm, Ute Ellert, Hans Werner Hense... Angelika Schaffrath Rosario ; originally published online March 7, 2011;

Hannelore K. Neuhauser, Michael Thamm, Ute Ellert, Hans Werner Hense... Angelika Schaffrath Rosario ; originally published online March 7, 2011;

Blood Pressure Percentiles by Age and Height From Nonoverweight Children
and Adolescents in Germany
Hannelore K. Neuhauser, Michael Thamm, Ute Ellert, Hans Werner Hense and
Angelika Schaffrath Rosario
Pediatrics 2011;127;e978; originally published online March 7, 2011;
DOI: 10.1542/peds.2010-1290
The online version of this article, along with updated information and services, is
located on the World Wide Web at:
http://pediatrics.aappublications.org/content/127/4/e978.full.html
PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly
publication, it has been published continuously since 1948. PEDIATRICS is owned,
published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point
Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2011 by the American Academy
of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.
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Blood Pressure Percentiles by Age and Height From
Nonoverweight Children and Adolescents in Germany
WHAT’S KNOWN ON THIS SUBJECT: Current pediatric US blood
pressure references are widely used internationally because of
scarce international data and rare percentile derivation by age
and height simultaneously. However, the US references may not
fit other populations, and improved statistical methods have
become available.
WHAT THIS STUDY ADDS: The German blood pressure
references by age and height from nonoverweight children and
adolescents aged 3 to 17 years use a national sample,
oscillometric measurements validated in children, and improved
statistical methods. These references were not influenced by the
increasing prevalence of overweight children in the sample.
abstract
AUTHORS: Hannelore K. Neuhauser, MD, MPH,a Michael
Thamm, MD,a Ute Ellert, PhD,a Hans Werner Hense, MD,
PhD,b and Angelika Schaffrath Rosario, MSca
aDepartment of Epidemiology and Health Reporting, Robert Koch
Institute, Berlin, Germany; and bInstitute for Epidemiology and
Social Medicine, University Muenster, Muenster, Germany
KEY WORDS
blood pressure, hypertension, population, population-based
study, percentiles
ABBREVIATIONS
BP—blood pressure
KiGGS—German Health Interview and Examination Survey for
Children and Adolescents
CDC—Centers for Disease Control and Prevention
SBP—systolic blood pressure
DBP—diastolic blood pressure
GAMLLS—generalized additive models for location scale and
shape
www.pediatrics.org/cgi/doi/10.1542/peds.2010-1290
doi:10.1542/peds.2010-1290
OBJECTIVES: To present oscillometric blood pressure (BP) references
from German nonoverweight children and compare them with US
references.
METHODS: From children and adolescents, aged 3 to 17 years, from
the German Health Interview and Examination Survey for Children and
Adolescents (KiGGS 2003–2006), we obtained standardized BP measurements by using an oscillometric device validated in children.
Gender-specific systolic (SBP) and diastolic (DBP) BP percentiles,
which simultaneously accounted for age and height by use of advanced
statistical methods, were derived from nonoverweight children to
avoid overweight prevalence in the reference population influencing
BP references.
Accepted for publication Dec 10, 2010
Address correspondence to Hannelore K. Neuhauser, MD, MPH,
Robert Koch Institute, Department of Epidemiology and Health
Reporting, General-Pape-Strasse 62-66, 12101 Berlin, Germany.
E-mail: [email protected]
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
Copyright © 2011 by the American Academy of Pediatrics
FINANCIAL DISCLOSURE: The authors have indicated they have
no financial relationships relevant to this article to disclose.
RESULTS: The age- and gender-specific 95th percentiles from nonoverweight children (n ⫽ 12 199) were lower by up to 3 mm Hg for SBP and
up to 2 mm Hg for DBP compared with the total sample (N ⫽ 14 349).
KiGGS percentiles from nonoverweight children accounting simultaneously for age and height were mostly lower than in the US reference
sample but higher for SBP in boys aged 14 years or older. At median
height, the age-specific differences in 95th percentiles of SBP ranged
from ⫺4 to 4 mm Hg in boys and ⫺2 to 1 mm Hg in girls and, for DBP,
from ⫺6 to 2 mm Hg in boys and ⫺5 to 2 mm Hg in girls.
CONCLUSIONS: Compared with current US references, the proposed
German BP reference values are not influenced by the prevalence of
overweight children in the reference population, they are based on a
validated oscillometric device, and they take advantage of improved
statistical methods. Pediatrics 2011;127:e978–e988
e978
NEUHAUSER et al
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ARTICLES
Elevated blood pressure (BP) in childhood and adolescence is increasingly
gaining attention because of its association with subclinical organ damage1–5 and to its tracking into adulthood hypertension.6 By widespread
convention, the 95th BP percentile of a
reference population defines hypertension and the 90th BP percentile defines prehypertension in children.
Older European reference values7 are
based on heterogeneous pooled data
from 6 regional European studies and
were dismissed in the 2009 Guidelines
for Management of High Blood Pressure
in Children and Adolescents: Recommendations of the European Society of Hypertension (2009 European guidelines)8 for
not accounting for age and height simultaneously. None of the few more recent
European reference values9–11 fulfill the
desirable criteria, foremost standardized BP measurement either using the
auscultatory method or an oscillometric method with good validation results (preferably in children), population sampling, a sufficiently large age
range, and reference value presentation by age and height percentile simultaneously. Therefore, the 2009 European guidelines recommend use of
the US reference values presented in
the “Fourth Report on the Diagnosis,
Evaluation, and Treatment of High
Blood Pressure in Children and Adolescents” (Fourth Report).12
The aim of this study was to present BP
reference values by age and height
from children and adolescents aged 3
to 17 years on the basis of a nationally
representative sample of 12 199 nonoverweight children and adolescents
who participated in the German Health
Interview and Examination Survey on
Children and Adolescents (KiGGS)
2003–2006 and had standardized BP
measurements with an oscillometric
device (Datascope Accutorr Plus [Datascope Corporation, Mahwah, NJ])
validated in children. We compared
PEDIATRICS Volume 127, Number 4, April 2011
these reference values with the
Fourth-Report references. In addition,
our goal was to illustrate how excluding overweight children affects BP
percentiles.
METHODS
Study Population
The KiGGS 2003–2006 study is a
population-based cross-sectional study
used to collect representative information on the health of children and adolescents aged 0 to 17 years living in Germany. The 2-stage sampling procedure
involved the selection of 167 study locations from strata formed according to
federal state, community type, and population size.13 In a second step, an equal
number of children per birth year from
each location were identified through local population registries and invited to
participate in the study. The response
rate was 66.6%, and 17 641 children and
adolescents aged 0 to 17 years participated in the study (8656 girls and 8985
boys). The study was approved by the
ethical committee of Charité–University
Medicine, Berlin, and by the Federal Commissioner for Data Protection and Freedom of Information. Informed written
consent and assent were obtained from
all parents and from adolescents aged
14 years or older. The KiGGS includes
17% of children with a 2-sided migration
background; migrants from Turkey and
the former Soviet Union were the 2 largest groups.13 A computer-assisted personal interview by a study physician
covered current and past medical conditions and medication within the 7 days
preceding the interview. The girls’ median age at menarche was 12.8 years,
and the boys’ voices started breaking/
reached full adult pitch at a median of
13.5/15.1 years.14
Measurements
In children aged 3 to 17 years, 2 readings of systolic blood pressure (SBP),
diastolic blood pressure (DBP), and
mean arterial BP and heart rate were
obtained by using an automated oscillometric device (Datascope Accutorr
Plus) at 2-minute intervals after a nonstrenuous part of the examination and
an additional 5-minute rest.15 The measurements were taken using the right
arm, in the sitting position with the elbow at the level of the right atrium,
using 1 of 4 cuff sizes (6 ⫻ 12, 9 ⫻ 18,
12 ⫻ 23, or 17 ⫻ 38.6 cm), which had to
cover at least two-thirds of the upper
arm length (from the axilla to the antecubital fossa). The mean of the 2 measurements was used for analysis.
Body height was measured by trained
staff according to a standardized protocol to the nearest 0.1 cm by using
portable devices (Harpenden Stadiometer; Holtain Ltd, Crymych, United Kingdom). Body weight was measured with
the child wearing only underwear to
the nearest 0.1 kg with a calibrated
scale (Seca, Birmingham, United Kingdom).13 BMI was calculated as the ratio
of weight (in kg) by height2 (in m2) and
rounded to 3 digits. A BMI at ⬎90th
percentile for gender and age was categorized as overweight according to
the current German reference system
by Kromeyer-Hauschild et al.16 KiGGS
BMI percentiles were published recently, but for individual diagnosis
of overweight, the references of
Kromeyer-Hauschild et al17 are still
recommended.
Inclusion and Exclusion Criteria
for the Sample on Which the
Percentiles Are Based
Of 14 836 KiGGS participants aged 3 to
17 years, we excluded 149 children
with missing or invalid BP or height
data, participants with chronic conditions possibly influencing growth (n ⫽
302)18 or BP (n ⫽ 30 [ie, chronic renal
diseases, aortic coarctation, hyperthyroidism, congenital adrenal hyperplasia, porphyria]) and children taking
antihypertensive agents (n ⫽ 25 [Ana-
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e979
tomical Therapeutic Chemical Classification System codes C01-03 and C07-09
or any medication given with the indication hypertension]). Seventeen children had ⬎1 exclusion criterion, leaving 7038 girls and 7311 boys for
analysis. For the BP percentiles by age
and height from nonoverweight children, an additional 2150 overweight
children were excluded (Table 1).
search Council, London, United Kingdom). The reference curves from nonoverweight children by age and height
simultaneously were fitted by using an
extension of the LMS method for 2 covariates, namely the generalized additive models for location scale and
shape (GAMLLS) with the Box-Cox-ColeGreen distribution family,20–22 fitted
with gamlss 1.9-4 in the free statistical
software R 2.8.0 (www.cran.r-project.
org). Both models require neither the
assumption of a normal distribution
nor of a constant variance of BP values
with age and/or height. The skewness
parameter L, the median M, and the
Statistical Analysis
BP percentiles as a function of either
age or height were modeled using
the LMS method19 with the program
LMSChartMaker Pro 2.2 (Medical Re-
TABLE 1 Baseline Characteristics of the Reference Population of Nonoverweight Children and
Adolescents (5989 Girls and 6210 Boys Aged 3–17 Years)
Age, y
3–6
Excluded only because of overweight, n
(weighted % of 7038 girls/7311
boys)
Boys
Girls
Children included, n
Boys
Girls
Weight, mean (SD), kg
Boys
Girls
Height, mean (SD), cm
Boys
Girls
BMI, mean (SD)
Boys
Girls
First SBP, mean (SD), mm Hg
Boys
Girls
Second SBP, mean (SD), mm Hg
Boys
Girls
Mean of first and second SBP, mean (SD),
mm Hg
Boys
Girls
First DBP, mean (SD), mm Hg
Boys
Girls
Second DBP, mean (SD), mm Hg
Boys
Girls
Mean of first and second DBP, mean (SD),
mm Hg
Boys
Girls
e980
NEUHAUSER et al
7–10
11–13
340 (15.8)
300 (14.7)
276 (18.2)
277 (18.6)
1719
1652
1716
1676
1240
1177
1535
1484
19.3 (3.4)
19.0 (3.5)
30.3 (5.7)
29.8 (6.1)
44.5 (8.7)
45.5 (8.3)
63.1 (9.5)
56.3 (7.1)
111.3 (8.7)
110.7 (8.9)
135.3 (8.3)
134.4 (8.9)
155.3 (9.6)
156.1 (8.3)
175.3 (8.2)
164.9 (6.4)
15.5 (1.0)
15.4 (1.1)
16.4 (1.6)
16.3 (1.8)
18.3 (2.1)
18.5 (2.2)
20.5 (2.2)
20.7 (2.1)
98.9 (8.4)
99.0 (8.3)
102.8 (8.3)
103.4 (8.7)
109.7 (9.7)
110.4 (9.3)
120.9 (11.7)
114.4 (10.0)
96.7 (8.1)
96.9 (8.2)
101.3 (8.2)
101.7 (8.3)
107.8 (9.7)
108.6 (8.8)
118.5 (10.8)
112.4 (9.3)
97.8 (7.6)
98.0 (7.6)
102.0 (7.7)
102.5 (8.0)
108.8 (9.2)
109.5 (8.4)
119.7 (10.6)
113.4 (9.1)
60.6 (8.2)
61.3 (8.2)
63.4 (7.9)
63.7 (7.6)
66.5 (8.5)
66.8 (7.8)
70.9 (8.6)
70.2 (8.1)
58.3 (7.5)
58.9 (7.5)
61.5 (7.6)
61.9 (7.6)
64.5 (8.1)
64.6 (7.5)
68.7 (8.5)
67.7 (7.7)
59.5 (6.8)
60.1 (6.7)
62.4 (6.7)
62.8 (6.6)
65.5 (7.3)
65.7 (6.7)
69.8 (7.6)
69.0 (7.1)
169 (8.9)
184 (9.4)
14–17
316 (16.9)
288 (16.5)
coefficient of variation S have been
modeled as a function of age and/or
height either as polynomials or nonparametrically by cubic splines. Height
was entered in centimeters or as z
scores (based on the KiGGS population18), and the version with the better
fit was used. Goodness of fit was examined via the generalized Akaike information criterion with k ⫽ 8,20 Q
tests,23,24 and wurmplots25 and by examining the percentage of data outside the smoothed percentiles.
Models were fit for boys and girls separately. DBP was normally distributed
but with a coefficient of variation S
that varied with age. Median DBP was
given by a function quadratic in age
and linear in height z score. SBP was
log-normally distributed in girls; in
boys, the distribution was even more
skewed. The model for the median included a linear and quadratic term in
age, a linear term for height and the
interaction terms height ⫻ age and
height ⫻ age.2 In boys, S varied with
age, whereas it was constant in girls.
Only selected percentiles were tabulated in this study, but any (100␣) percentile P␣ can be calculated as
P␣ ⫽ M(1 ⫹ LSz␣)1⁄L for L ⫽ 0
or
P␣ ⫽ M ⫻ exp(Sz␣) for L ⫽ 0,
with z␣ the ␣ quantile of a standard
normal distribution. For example, the
10th SBP percentile for a boy at 10
years and 140 cm is given by
103(1 ⫹
[⫺0.4685]0.0734[⫺1.282])⫺1⁄0.4685 ⫽
103 ⫻ 1.044⫺2.1345
and for a girl at this age and height by
104 ⫻ exp(0.0763[⫺1.282]),
both of which equal 94 mm Hg. Age in
years was used as a continuous variable and calculated to 3 decimal
places. Fourth-Report values were calculated from the published formula12
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ARTICLES
by using age as 3.5, 4.5, 5.5 and so in
years. Calculations apart from the fitting
of the percentile curves were conducted
using SAS 9.2 (SAS Institute Inc, Cary, NC).
Sampling weights were used to account for unequal sampling probabilities and to reflect the distribution of
the population in Germany.13
RESULTS
The reference population of nonoverweight children and adolescents aged
3 to 17 years consisted of 6210 boys
and 5989 girls. Baseline characteristics of the nonoverweight reference
population are shown in Table 1.
Smoothed BP percentiles from nonoverweight children by age and height
are shown in Tables 2 and 3. These BP
references do not require consultation
of additional height reference tables
because the height percentiles are
given in cm.
BP increased in children and adolescents aged 3 to 17 years by both age
and height percentile. SBP and DBP
were very similar in boys and girls until age 13 years. The pubertal rise was
more pronounced in boys than in girls,
resulting in BP differences between
boys and girls up to 17 mm Hg for SBP
95th percentile and 2 mm Hg for DBP
95th percentile (at age 17.99 years,
both for the 90th height percentile). At
a given age and gender, BP percentiles
vary by height. Figure 1 illustrates how
the 95th BP percentile, which is commonly taken for the definition of hypertension in children and adolescents,
differs between the 5th and the 95th
height percentile: SBP in boys by 2 to 8
mm Hg and in girls by 2 to 6 mm Hg and
DBP by 2 mm Hg in both boys and girls.
To illustrate the impact of excluding
overweight children from the reference population, we compared BP percentiles from nonoverweight children
with those calculated without excluding overweight children (all other exclusion criteria being the same). The
PEDIATRICS Volume 127, Number 4, April 2011
exclusion of overweight children resulted in slightly lower SBP and DBP for
all percentiles both by age (Fig 2) and
by height (data not shown but similar).
This difference was more pronounced
with increasing age and height and
was generally more pronounced for
the higher percentiles and in boys. For
example, the difference between agespecific 95th percentiles for SBP from
the samples with and without overweight children in boys aged 14 to 17
years was 2.6 to 2.7 mm Hg and in girls
it was 1.3 to 1.6 mm Hg. For DBP, the
difference between age-specific 95th
percentiles from the samples with and
without overweight children aged 14 to
17 years was 1.1 to 1.7 mm Hg in boys
and 0.1 to 0.6 mm Hg in girls.
We compared KiGGS and Fourth-Report
BP percentiles, both modeled by age
and height simultaneously. Of note,
KiGGS references are based on a
nonoverweight reference population
whereas overweight children were not
excluded from the Fourth-Report data
set. Fig 3 shows KiGGS and FourthReport BP percentiles by age, both for
median height according to Centers
for Disease Control and Prevention
(CDC) growth charts (www.cdc.gov/
growthcharts). Fourth-Report percentiles, which are based on a model that
differs statistically from the KiGGS
model, show a higher spread between
the median and the outer percentiles.
The 90th and 95th percentiles were
mostly lower in the KiGGS, but they
were higher for SBP in boys aged ⬎14
years. At median CDC height, the difference for the 95th percentile (KiGGS minus Fourth-Report values) ranged by
age for SBP from ⫺4 to 4 mm Hg in
boys and ⫺2 to 1 mm Hg in girls; and
for DBP from ⫺6 to 2 mm Hg in boys
and ⫺5 to 2 mm Hg in girls.
DISCUSSION
This study presents BP references by
age and height simultaneously for chil-
dren and adolescents aged 3 to 17
years. These findings are based on
standardized BP measurements using
a validated oscillometric device (Datascope Accutorr Plus) on a nationally
representative sample of 12 199 nonoverweight children from the KiGGS
2003–2006 study in Germany. These
references use both a database with
high validity as a normative population
and improved statistical methods for
percentile derivation. However, KiGGS
BP data are influenced by the BP epidemic, which has touched Germany.17
Because of the strong relationship between BP and overweight and obesity,26 the inclusion of this high proportion of overweight subjects would
raise the threshold for normal BP (because it would include those with
obesity-induced BP elevations in the
normative population). As a result,
obesity-related BP elevations would be
more difficult to detect (ie, the references would be less sensitive to
obesity-related hypertension than references based on older data). To avoid
this, we excluded overweight children
from the reference population.
The widely used Fourth-Report BP references12 did not exclude overweight
children, but we compared them with
the KiGGS references because they are
both screening and detection tools for
the same problem— elevated BP in
children. As expected, we found mostly
lower 90th and 95th percentiles in the
KiGGS compared with the Fourth Report (by 2– 6 mm Hg). In a reanalysis of
the Fourth-Report sample excluding
overweight children,27 prehypertension thresholds were only 1 to 3 mm Hg
lower than in the Fourth Report. Our
analyses confirm these rather small
differences between percentiles with
and without overweight children. A few
mm Hg may be less relevant for the
individual diagnosis of hypertension,
for which measurements on multiple
occasions are needed and both intra-
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e981
TABLE 2 BP Levels from Nonoverweight Boys According to Age and Height (KiGGS Survey 2003–2006)
Age,
y
3
4
5
6
7
8
9
10
11
e982
Height,
cm
95
96
98
101
104
106
108
101
103
105
108
111
114
115
107
109
111
115
118
121
123
113
115
118
121
125
128
130
119
121
124
128
131
135
137
124
126
130
134
138
141
143
129
131
135
139
143
147
149
133
136
140
144
149
153
155
137
140
144
149
154
159
162
SBP, mm Hg
DBP, mm Hg
S
50th Percentile
(Median)
90th
Percentile
95th
Percentile
99th
Percentile
S
50th Percentile
(Median)
90th
Percentile
95th
Percentile
99th
Percentile
0.0767
0.0767
0.0767
0.0767
0.0767
0.0767
0.0767
0.0753
0.0753
0.0753
0.0753
0.0753
0.0753
0.0753
0.0740
0.0740
0.0740
0.0740
0.0740
0.0740
0.0740
0.0730
0.0730
0.0730
0.0730
0.0730
0.0730
0.0730
0.0724
0.0724
0.0724
0.0724
0.0724
0.0724
0.0724
0.0723
0.0723
0.0723
0.0723
0.0723
0.0723
0.0723
0.0727
0.0727
0.0727
0.0727
0.0727
0.0727
0.0727
0.0734
0.0734
0.0734
0.0734
0.0734
0.0734
0.0734
0.0746
0.0746
0.0746
0.0746
0.0746
0.0746
0.0746
96
96
96
96
97
97
97
96
96
96
97
97
98
98
96
97
97
97
98
98
99
97
97
98
98
99
100
100
98
98
99
100
100
101
101
99
100
100
101
102
102
103
100
101
102
102
103
104
104
102
102
103
104
105
106
106
103
104
105
106
107
108
109
106
106
106
107
107
107
108
106
106
106
107
107
108
108
106
106
107
107
108
108
109
107
107
108
108
109
109
110
108
108
109
110
110
111
111
109
109
110
111
112
113
113
111
111
112
113
114
114
115
112
113
114
115
116
117
117
114
115
116
117
118
119
120
109
109
109
110
110
111
111
109
109
110
110
110
111
111
109
109
110
110
111
112
112
110
110
111
111
112
113
113
111
111
112
113
113
114
114
112
113
113
114
115
116
116
114
114
115
116
117
118
118
115
116
117
118
119
120
121
117
118
119
120
122
123
123
115
115
116
116
117
117
117
115
115
116
116
117
117
118
115
116
116
117
117
118
118
116
116
117
117
118
119
119
117
117
118
119
119
120
121
118
119
119
120
121
122
122
120
120
121
122
123
124
125
122
122
123
124
126
127
127
124
125
126
127
128
130
130
0.1171
0.1171
0.1171
0.1171
0.1171
0.1171
0.1171
0.1139
0.1139
0.1139
0.1139
0.1139
0.1139
0.1139
0.1110
0.1110
0.1110
0.1110
0.1110
0.1110
0.1110
0.1085
0.1085
0.1085
0.1085
0.1085
0.1085
0.1085
0.1067
0.1067
0.1067
0.1067
0.1067
0.1067
0.1067
0.1054
0.1054
0.1054
0.1054
0.1054
0.1054
0.1054
0.1046
0.1046
0.1046
0.1046
0.1046
0.1046
0.1046
0.1045
0.1045
0.1045
0.1045
0.1045
0.1045
0.1045
0.1048
0.1048
0.1048
0.1048
0.1048
0.1048
0.1048
58
58
58
59
59
59
59
58
58
59
59
60
60
60
59
59
59
60
60
60
61
60
60
60
60
61
61
61
60
61
61
61
62
62
62
61
61
62
62
62
63
63
62
62
62
63
63
63
64
63
63
63
64
64
64
65
64
64
64
65
65
65
66
66
67
67
67
68
68
68
67
67
67
68
68
69
69
67
67
68
68
69
69
69
68
68
68
69
69
70
70
69
69
69
70
70
70
71
69
70
70
70
71
71
71
70
70
71
71
72
72
72
71
71
72
72
73
73
73
72
73
73
73
74
74
74
69
69
69
70
70
71
71
69
69
70
70
71
71
71
70
70
70
71
71
71
72
70
70
71
71
72
72
72
71
71
71
72
72
73
73
72
72
72
73
73
73
74
73
73
73
74
74
74
75
74
74
74
75
75
75
76
75
75
75
76
76
77
77
73
74
74
75
75
75
76
74
74
74
75
75
76
76
74
74
75
75
76
76
76
75
75
75
76
76
77
77
75
76
76
76
77
77
77
76
76
77
77
78
78
78
77
77
78
78
79
79
79
78
78
79
79
80
80
80
79
80
80
80
81
81
82
NEUHAUSER et al
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ARTICLES
TABLE 2 Continued
Age,
y
12
13
14
15
16
17
Height,
cm
142
145
150
155
161
166
169
149
152
157
163
169
174
177
157
160
165
170
176
181
184
163
165
170
175
180
185
187
166
169
173
178
182
186
189
167
170
174
179
183
187
189
SBP, mm Hg
DBP, mm Hg
S
50th Percentile
(Median)
90th
Percentile
95th
Percentile
99th
Percentile
S
50th Percentile
(Median)
90th
Percentile
95th
Percentile
99th
Percentile
0.0762
0.0762
0.0762
0.0762
0.0762
0.0762
0.0762
0.0780
0.0780
0.0780
0.0780
0.0780
0.0780
0.0780
0.0799
0.0799
0.0799
0.0799
0.0799
0.0799
0.0799
0.0819
0.0819
0.0819
0.0819
0.0819
0.0819
0.0819
0.0839
0.0839
0.0839
0.0839
0.0839
0.0839
0.0839
0.0860
0.0860
0.0860
0.0860
0.0860
0.0860
0.0860
105
106
107
109
110
111
112
108
109
110
112
113
114
115
111
112
113
115
116
118
118
115
115
117
118
119
120
121
117
118
119
120
122
123
124
119
120
121
123
124
125
126
117
117
119
120
121
123
123
120
121
122
124
125
127
127
124
125
126
128
129
131
131
128
128
130
131
133
134
135
131
132
133
134
136
137
138
134
135
136
137
139
140
141
120
121
122
123
125
126
127
123
124
126
127
129
130
131
128
128
130
132
133
135
135
132
132
134
135
137
138
139
135
136
137
139
140
142
142
138
139
141
142
144
145
146
127
128
129
131
132
133
134
131
132
133
135
137
138
139
135
136
138
140
141
143
144
140
141
142
144
146
147
148
144
145
146
148
149
151
152
147
148
150
151
153
154
155
0.1053
0.1053
0.1053
0.1053
0.1053
0.1053
0.1053
0.1060
0.1060
0.1060
0.1060
0.1060
0.1060
0.1060
0.1065
0.1065
0.1065
0.1065
0.1065
0.1065
0.1065
0.1069
0.1069
0.1069
0.1069
0.1069
0.1069
0.1069
0.1072
0.1072
0.1072
0.1072
0.1072
0.1072
0.1072
0.1074
0.1074
0.1074
0.1074
0.1074
0.1074
0.1074
65
65
65
66
66
66
67
66
66
66
67
67
67
68
67
67
68
68
68
69
69
68
68
69
69
69
70
70
69
70
70
70
71
71
71
71
71
71
72
72
72
72
74
74
74
75
75
75
76
75
75
75
76
76
77
77
76
76
77
77
78
78
78
78
78
78
79
79
79
80
79
79
80
80
80
81
81
80
81
81
81
82
82
82
76
76
77
77
77
78
78
77
78
78
78
79
79
79
79
79
79
80
80
81
81
80
80
81
81
82
82
82
82
82
82
83
83
84
84
83
83
84
84
85
85
85
81
81
81
82
82
83
83
82
82
83
83
84
84
84
84
84
84
85
85
86
86
85
85
86
86
87
87
87
87
87
87
88
88
89
89
88
89
89
90
90
90
91
Height in centimeters for each age represents the 5th, 10th, 25th, 50th, 75th, 90th, and 95th percentile. The height percentiles are derived from the overall KiGGS population18 and are
representative for Germany 2003–2006.
BP percentiles apply exactly for the midpoint of each age group (eg, 3 years 6 months old) and can be applied to all children of that age.
LMS skewness parameter L ⫽ ⫺0.4685 for SBP and L ⫽ 1 for DBP.
individual variation and inaccuracy of
the BP device may be larger. However,
for population monitoring of BP levels
over time and for international comparisons, a shift of the whole BP distribution of a few mm Hg is rather large
because it has a substantial effect on
the prevalence of hypertension28 and
on hypertension-related outcomes. In
adults, for example, a 4 –mm Hg differPEDIATRICS Volume 127, Number 4, April 2011
ence in mean blood pressure level may
lead to a 20% difference in stroke
death.29
Additional reasons that may contribute to the lower KiGGS nonoverweight
BP percentiles compared with the
Fourth-Report percentiles are the oscillometric BP measurement in the
KiGGS, which according to the Datascope Accutorr validation study in chil-
dren30 may lead to readings ⬃1 mm Hg
(mean) less than auscultatory SBP and
DBP, and the use of the mean of 2 readings in the KiGGS. However, not all
KiGGS percentiles are lower, and it is
not possible to merely modify the
Fourth-Report percentile cutoff for a
definition of prehypertension or hypertension. For example, thresholds for
hypertensive SBP in boys aged ⬎14
Downloaded from pediatrics.aappublications.org by guest on August 22, 2014
e983
TABLE 3 BP Levels from Nonoverweight Girls According to Age and Height (KiGGS Survey 2003–2006)
Age,
y
3
4
5
6
7
8
9
10
11
e984
Height,
cm
94
95
97
100
102
105
106
100
102
104
107
110
113
114
107
108
111
114
117
120
122
112
114
117
121
124
127
129
118
120
123
127
130
133
135
123
125
128
132
136
140
142
128
130
134
138
142
146
149
133
136
140
144
149
153
155
140
142
146
151
156
160
162
SBP, mm Hg
DBP, mm Hg
S
50th Percentile
(Median)
90th
Percentile
95th
Percentile
99th
Percentile
S
50th Percentile
(Median)
90th
Percentile
95th
Percentile
99th
Percentile
0.0763
0.0763
0.0763
0.0763
0.0763
0.0763
0.0763
0.0763
0.0763
0.0763
0.0763
0.0763
0.0763
0.0763
0.0763
0.0763
0.0763
0.0763
0.0763
0.0763
0.0763
0.0763
0.0763
0.0763
0.0763
0.0763
0.0763
0.0763
0.0763
0.0763
0.0763
0.0763
0.0763
0.0763
0.0763
0.0763
0.0763
0.0763
0.0763
0.0763
0.0763
0.0763
0.0763
0.0763
0.0763
0.0763
0.0763
0.0763
0.0763
0.0763
0.0763
0.0763
0.0763
0.0763
0.0763
0.0763
0.0763
0.0763
0.0763
0.0763
0.0763
0.0763
0.0763
95
96
96
97
97
98
98
95
96
96
97
98
98
99
96
96
97
98
99
99
100
97
97
98
99
100
101
101
98
98
99
100
101
102
102
99
100
101
102
103
104
104
101
101
102
103
104
105
106
103
103
104
105
106
107
108
105
105
106
107
109
110
110
105
105
106
106
107
108
108
105
106
106
107
108
108
109
106
106
107
108
109
109
110
107
107
108
109
110
111
111
108
109
109
110
112
112
113
109
110
111
112
113
114
115
111
112
113
114
115
116
117
113
114
115
116
117
118
119
115
116
117
118
120
121
121
108
108
109
109
110
111
111
108
109
109
110
111
111
112
109
109
110
111
112
113
113
110
110
111
112
113
114
114
111
112
113
114
115
116
116
113
113
114
115
116
117
118
114
115
116
117
118
120
120
116
117
118
119
121
122
123
119
119
120
122
123
124
125
114
114
115
115
116
116
117
114
114
115
116
117
117
118
115
115
116
117
118
119
119
116
116
117
118
119
120
121
117
118
119
120
121
122
122
119
119
120
121
123
124
124
120
121
122
123
125
126
127
122
123
124
126
127
128
129
125
126
127
128
130
131
132
0.1173
0.1173
0.1173
0.1173
0.1173
0.1173
0.1173
0.1137
0.1137
0.1137
0.1137
0.1137
0.1137
0.1137
0.1106
0.1106
0.1106
0.1106
0.1106
0.1106
0.1106
0.1079
0.1079
0.1079
0.1079
0.1079
0.1079
0.1079
0.1056
0.1056
0.1056
0.1056
0.1056
0.1056
0.1056
0.1037
0.1037
0.1037
0.1037
0.1037
0.1037
0.1037
0.1022
0.1022
0.1022
0.1022
0.1022
0.1022
0.1022
0.1011
0.1011
0.1011
0.1011
0.1011
0.1011
0.1011
0.1003
0.1003
0.1003
0.1003
0.1003
0.1003
0.1003
58
59
59
59
60
60
60
59
59
59
60
60
60
61
60
60
60
60
61
61
61
60
60
61
61
61
62
62
61
61
61
62
62
62
63
62
62
62
62
63
63
63
62
63
63
63
64
64
64
63
63
64
64
64
65
65
64
64
64
65
65
65
66
67
67
68
68
69
69
69
68
68
68
69
69
69
69
68
68
69
69
69
70
70
69
69
69
69
70
70
70
69
69
70
70
70
71
71
70
70
70
71
71
71
72
70
71
71
71
72
72
72
71
72
72
72
73
73
73
72
72
73
73
73
74
74
70
70
70
71
71
71
72
70
70
71
71
71
72
72
70
71
71
71
72
72
72
71
71
71
72
72
73
73
71
72
72
72
73
73
73
72
72
73
73
73
74
74
73
73
73
74
74
75
75
74
74
74
75
75
75
76
74
75
75
75
76
76
76
74
75
75
75
76
76
77
75
75
75
76
76
76
77
75
75
76
76
76
77
77
75
76
76
76
77
77
77
76
76
76
77
77
78
78
76
77
77
77
78
78
79
77
77
78
78
79
79
79
78
78
79
79
79
80
80
79
79
79
80
80
81
81
NEUHAUSER et al
Downloaded from pediatrics.aappublications.org by guest on August 22, 2014
ARTICLES
TABLE 3 Continued
Age,
y
12
13
14
15
16
17
Height,
cm
146
149
153
157
162
166
168
150
153
157
161
166
170
172
153
156
159
164
168
172
174
155
157
161
165
169
173
176
155
157
161
165
170
174
176
155
157
161
166
170
174
176
SBP, mm Hg
DBP, mm Hg
S
50th Percentile
(Median)
90th
Percentile
95th
Percentile
99th
Percentile
S
50th Percentile
(Median)
90th
Percentile
95th
Percentile
99th
Percentile
0.0763
0.0763
0.0763
0.0763
0.0763
0.0763
0.0763
0.0763
0.0763
0.0763
0.0763
0.0763
0.0763
0.0763
0.0763
0.0763
0.0763
0.0763
0.0763
0.0763
0.0763
0.0763
0.0763
0.0763
0.0763
0.0763
0.0763
0.0763
0.0763
0.0763
0.0763
0.0763
0.0763
0.0763
0.0763
0.0763
0.0763
0.0763
0.0763
0.0763
0.0763
0.0763
107
107
108
109
110
111
112
108
109
110
111
112
113
113
110
110
111
112
113
113
114
111
111
112
113
113
114
114
112
112
113
113
114
115
115
113
113
114
114
115
115
115
118
118
119
121
122
123
123
120
120
121
122
123
124
125
121
122
122
123
124
125
126
122
123
123
124
125
126
126
124
124
124
125
126
126
127
125
125
125
126
126
127
127
121
122
123
124
125
126
127
123
124
125
126
127
128
128
125
125
126
127
128
129
129
126
126
127
128
129
129
130
127
127
128
129
129
130
130
128
129
129
129
130
130
131
128
128
129
131
132
133
134
130
130
131
132
133
135
135
131
132
133
134
135
136
136
133
133
134
135
135
136
137
134
134
135
135
136
137
137
135
135
136
136
137
137
138
0.0998
0.0998
0.0998
0.0998
0.0998
0.0998
0.0998
0.0997
0.0997
0.0997
0.0997
0.0997
0.0997
0.0997
0.0999
0.0999
0.0999
0.0999
0.0999
0.0999
0.0999
0.1005
0.1005
0.1005
0.1005
0.1005
0.1005
0.1005
0.1013
0.1013
0.1013
0.1013
0.1013
0.1013
0.1013
0.1026
0.1026
0.1026
0.1026
0.1026
0.1026
0.1026
65
65
65
66
66
66
66
66
66
66
67
67
67
67
67
67
67
67
68
68
68
68
68
68
68
69
69
69
69
69
69
70
70
70
70
70
70
70
71
71
71
71
73
73
74
74
74
75
75
74
74
75
75
75
76
76
75
75
76
76
77
77
77
76
77
77
77
78
78
78
78
78
78
79
79
79
79
79
79
79
80
80
81
81
75
76
76
76
77
77
77
76
77
77
77
78
78
78
78
78
78
79
79
79
80
79
79
79
80
80
81
81
80
80
81
81
81
82
82
81
82
82
82
83
83
83
80
80
80
81
81
82
82
81
81
82
82
82
83
83
82
82
83
83
84
84
84
83
84
84
84
85
85
86
85
85
85
86
86
87
87
86
87
87
87
88
88
88
Height in centimeters for each age represents the 5th, 10th, 25th, 50th, 75th, 90th, and 95th percentile. The height percentiles are derived from the overall KiGGS population18 and are
representative for Germany 2003–2006.
BP percentiles apply exactly for the midpoint of each age group (eg, 3 years 6 months old) and can be applied to all children of that age.
LMS skewness parameter L ⫽ 0 for SBP and L ⫽ 1 for DBP.
years are higher than Fourth-Report
thresholds (eg, for median CDC height
4 mm Hg higher SBP 95th percentile in
boys aged 17 years). Of note, some of
the KiGGS differences compared with
the Fourth-Report findings, in particular the lower Fourth-Report SBP 95th
percentile in adolescent boys, may be
a statistical effect because of different
statistical models. We applied the
PEDIATRICS Volume 127, Number 4, April 2011
Fourth-Report model to KiGGS data and
found, for example, for a boy 17.5 years
old and 176 cm tall, a SBP 95th percentile of 137 mm Hg, whereas the GAMLSS
method yielded 141 mm Hg. It has been
shown recently that the Fourth-Report
model assumptions do not hold true
and that methods which do not require
normal distribution of BP or constant
variance at all ages (eg, the GAMLSS
method we have used) provide a better
fit.27,31 Thus, Fourth-Report BP percentiles seem less appropriate for Germany, not only because of geographic,
ethnic, and time-related differences in
the reference populations, but also for
statistical reasons.
The old European references7 are
based on heterogeneous pooled data
Downloaded from pediatrics.aappublications.org by guest on August 22, 2014
e985
FIGURE 1
95th percentile of BP according to age and height percentile among nonoverweight children aged 3 to
17 years. A, Boys; B, girls. Pn indicates nth percentile.
FIGURE 2
Comparison of KiGGS BP percentiles according to age based on the nonoverweight KiGGS population, KiGGS BP percentiles according to age based on the overall KiGGS population including
overweight children, and old European references according to age. A, Boys; B, girls. Pn indicates
nth percentile.
from 1975 to 1984 and are stratified
according to age or height alone. However, our data show that at the same
height (rounded to 5 cm), boys may differ in age by up to 5 years (5th–95th
e986
NEUHAUSER et al
percentile of age) and girls by up to 7
years, with resulting SBP 95th percentile differences of 12 and 6.5 mm Hg.
Conversely, at the same age, height differences in boys and girls of up to 28
and 23 cm are possible (height 95th–
5th percentile) with maximum SBP
95th percentile differences of 8 and 6
mm Hg. The old European references
represented the best data available at
the time but have various limitations
such as selection bias and heterogeneous measurement methods. This
may explain the rather large differences in systolic BP distribution compared with the KiGGS (Fig 2). These differences are best seen by comparing
the older European references with
the KiGGS percentiles by age including
overweight children: KiGGS SBP 95th
percentile by age including overweight
children are 6 to 7 mm Hg lower in
most age groups in boys and 3 to 7
mm Hg lower in girls compared with
the old European references. A secular
trend in BP cannot be excluded but
should not be affirmed on the basis of
a comparison of KiGGS data with old
European data, which have too many
methodologic caveats.
BP references that include age, gender, and height together are scarce. In
addition to the Fourth-Report research12 and the separate analysis of
these data after exclusion of overweight children,27 Norwegian oscillometric (Criticare 507N [Criticare Systems Inc., Waukesha, Wisconsin, USA])
BP percentiles by age and height have
been reported from nonoverweight adolescents aged 13 to 18 years.11 However, they are considerably higher not
only than the KiGGS percentiles from
nonoverweight children but also the
British and US references that did not
exclude overweight children.10,12 Recently, Hong Kong Chinese BP references by age and height based on the
same oscillometric BP-measuring device as used in the KiGGS have been
published.32 They included overweight
children and are mostly higher than
KiGGS references from nonoverweight
children but are quite similar to the
KiGGS overall sample distribution.
Downloaded from pediatrics.aappublications.org by guest on August 22, 2014
ARTICLES
Another possible limitation of the
KiGGS is selection bias. However, the
response rate was good (67%), and
two-thirds of nonresponders answered a short questionnaire including self-reported height and weight.
Self-reported BMI of responders and
nonresponders by age and gender was
not significantly different,36 indicating
that an adverse impact of nonresponder bias is unlikely.
CONCLUSIONS
FIGURE 3
Comparison of KiGGS BP references from nonoverweight children and Fourth-Report BP references12
(for median CDC height). A, Boys; B, girls. Pn indicates nth percentile.
Major strengths of the KiGGS BP references are the large and nationally representative sample, coverage of a wide age
range, standardized measurements of
BP and height, use of a BP device validated in children, averaging of 2 BP measurements per participant, and the modeling by age and height simultaneously
with flexible statistical techniques that
do not impose normality or constant
variance assumptions on the data.
A possible limitation of the KiGGS is the
use of an oscillometric BP-measuring
device, whereas current guidelines
still recommend the auscultatory
method as a first choice.8,12 However,
these guidelines acknowledge that
some oscillometric devices have been
successfully validated using established protocols and that because of
the banning of mercury devices, oscillometric reference data will be increasingly needed. In addition, oscillo-
metric BP measurements have the
advantage of largely eliminating observer error. The Datascope Accutorr
Plus device has passed the standards
of the Association for the Advancement
of Medical Instrumentation33 and of the
British Hypertension Society34 in adults
and has been also validated in children
aged 5 to 15 years against mercury
sphygmomanometric measurements
according to the international protocol
of the European Society of Hypertension.35 In the validation study in
children,30 Datascope Accutorr Plus
closely matched sphygmomanometric
measurements: the mean (SD) of the
differences for SBP readings (oscillometric minus auscultatory) was ⫺0.9
(4.3) mm Hg and for DBP it was ⫺1.2
(6.5) mm Hg. Although this is a closer
match than previously reported for
other oscillometric BP measurement devices, validation protocols often differ.
The references presented here are, to
our knowledge, the first European BP references by age and height simultaneously based on oscillometric measurements with a device validated in
children. Compared with current US BP
references, the proposed KiGGS BP reference values are not influenced by the
prevalence of overweight children in the
reference population and take advantage of improved statistical methods.
Follow-up BP measurements in KiGGS
participants will be forthcoming and
will allow an analysis of the predictive
value of the presented thresholds for
reaching adolescent and early adult
hypertension thresholds as well as
tracking of specific BP percentiles.
ACKNOWLEDGMENTS
The KiGGS was funded by the German
Ministry of Health, the Ministry of Education and Research, and the Robert
Koch Institute.
We thank Professor Wolfgang Rascher for valuable advice on BP measurement issues, Professor Johannes Peter Haas for discussions
on BP plausibility checks, and Dr
Karen Atzpodien for advice on exclusion criteria.
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Blood Pressure Percentiles by Age and Height From Nonoverweight Children
and Adolescents in Germany
Hannelore K. Neuhauser, Michael Thamm, Ute Ellert, Hans Werner Hense and
Angelika Schaffrath Rosario
Pediatrics 2011;127;e978; originally published online March 7, 2011;
DOI: 10.1542/peds.2010-1290
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