Over the last several years, clinical knowlege of hypertension (HTN) in children and adolescents has gained ground in cardiovascular (CV) medicine thanks to the progress made in several areas of pathophysiological and clinical research. Measurements are fundamental to all sciences, including medicine, and the measurement of blood pressure (BP) is essential in HTN for both its detection and management. The need to measure BP in children and adolescents is highlighted in all recent paediatric guidelines,1–3 each emphasising the requirement for an accurate methodology of BP measurement, which is the cornerstone for HTN diagnosis and management.

The relevance of HTN in children and adolescents is based on several aspects. Paediatric HTN has an estimated prevalence of ~4%.4 In youth, the presence of HTN is associated with early markers of CV disease. Blood pressure percentiles in childhood tracks into adulthood, at which point it becomes a major contributor to the development of CV events. Lack of diagnosis prevents the initiation of guideline-based treatments, including lifestyle modification and medication. Taking this all into consideration, timely recognition of paediatric HTN is needed to reduce long-term morbidity and mortality.

It is important to highlight that in children and adolescents, BP depends on sex and normally changes with increasing age and body size. This means that establishing a fixed cut-off for values of systolic BP (SBP) and diastolic BP (DBP) elevation is problematic. This difficulty has led to the use of BP percentiles based on sex, age and height to define the normal distribution, with a hypertensive level of BP defined as the 95th percentile or higher. Given the variability of BP, the definition of HTN has required that SBP and/or DBP be persistently higher than the established thresholds on three separate occasions.1–3

Office BP measurement has provided the basis for the present knowledge of the potential risk associated with HTN and has guided patient management in untreated and treated patients for many years. The first and most important requirement for the diagnosis and management of HTN is an accurate measurement of office BP. Although office BP should be used as a reference, BP values obtained out of office may improve the evaluation. Development of methods and devices to obtain a large number of measurements outside the clinical setting and under normal living conditions can expand the understanding of BP levels and variability throughout the day and night. Strong evidence for the diagnostic and clinical value of 24-hour ambulatory BP monitoring (ABPM) in children has justified its central role in decision-making in the paediatric guidelines of the European Society of Hypertension (ESH) and the American and Canadian guidelines.1–3 The other method of out-of-office measurement is home BP measurement (HBPM). In contrast to 24-hour ABPM, there is little evidence for the use of HBPM in children and adolescents. Regarding HBPM, the American Association of Pediatrics guidelines state that because of limited evidence, the method should not be used for diagnosis.2 Considering that 24-hour ABPM is not widely available in primary care, the ESH guidelines recommend the use of HBPM only for follow-up and mainly in children during treatment with a methodology as follows: daily BP measurements for at least 3–4 days, preferably 7 consecutive days, in the mornings and evenings prior to a planned clinical (or remote) visit.1 Furthermore, the guidelines point out that more research on HBPM in children is needed.1 2

It is with great interest to read the results of the study by Mackay et al. 5 The authors move forward the topic of HBPM, analysing the acceptability and feasibility of HBPM in children and adolescents from age 5 to 18 years by measuring BP using a validated device for children during 3 consecutive days and excluding patients with elevated BP or HTN. Home SBP and DBP were statistically similar to both the clinic manual and automatic readings. Compared with clinic manual measurements, the mean difference was –2.3 mm Hg for SBP (95% CI: –4.78 to 0.13, p=0.06) and –1.9 mm Hg for DBP (95% CI: –4.80 to 0.93, p=0.18). Compared with clinic automatic values, the mean difference was –1.2 mm Hg for SBP (p=0.47) and 2.5 mm Hg for DBP (p=0.11), indicating no significant differences. The families received training on the proper use of a validated device and were provided with a study booklet that repeated these instructions. At the end of the study, the families were asked to complete an end-of-study survey to provide feedback and investigate health economic factors. All data was uploaded either by the research team or by the families themselves via the QR codes using REDCap electronic data tools hosted at the Murdoch Children’s Research Institute and the Royal Children’s Hospital, Melbourne. Participants and their families reported that the HBPM was easy, took 10 minutes, and minimally interrupted family life. Families also largely preferred home BP screening. These findings show high acceptance and adherence by participants and families, crucial for successful HBPM use in children, where cooperation between children and caregivers is key. This low-burden process, about 10 min daily, likely supports better adherence compared with 24-hour ABPM, which is often uncomfortable and disruptive.

The growing use of telemedicine opens new opportunities for HBPM. Digital platforms and Bluetooth-enabled monitors can streamline data sharing with healthcare providers, reducing clinic visits and enabling early intervention. In Mackay’s study, REDCap tools and QR code uploads illustrate how technology can support clinical workflows.

Cost is another important consideration. While 24-hour ABPM is more resource-intensive and less available in many primary care settings, HBPM offers a relatively affordable and scalable alternative for follow-up and long-term monitoring. Future cost-effectiveness studies should evaluate not just device costs but also reductions in clinic time, improved parental satisfaction, and early identification of elevated BP patterns.

Home BP measurement is well accepted by users and has a relatively low cost. The development of telemedicine using automatic devices with data transmission, telephone applications, and programmes facilitating the monitoring of BP in children creates new prospects and possibilities for the development of the use of HBPM in children. Relevant research questions on the practical application of HBPM in the paediatric population should be addressed in future studies.

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The author thanks professors Empar Lurbe (Spain) and Justin Davies (UK) for help in writing this manuscript.