http:// ijp.mums.ac.

ir
Original Article (Pages: 2153-2166)

Blood Pressure Nomograms by Age and Weight for Iranian

Children and Adolescents
Mostafa Hosseini1, Masoud Baikpour2, Mahmoud Yousefifard3, Mehdi Yaseri1, Mohammad
Fayaz4, Hoda Shirafkan1, Arash Abbasi5,6, Hadi Asady7, Faezeh Javidilarijani5,8, Behnaz
Bazargani5,6, *Neamatollah Ataei5,61
1
Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical
Sciences, Tehran, Iran. 2Department of Medicine, School of Medicine, Tehran University of Medical Sciences,
Tehran, Iran. 3Physiology Research Center and Department of Physiology, Faculty of Medicine, Iran University
of Medical Sciences, Tehran, Iran. 4Department of Biostatistics, School of Allied Medical Sciences, Shahid
Beheshti University of Medical Sciences, Tehran, Iran. 5Pediatric Chronic Kidney Disease Research Center, The
Children’s Hospital Medical Center, Tehran University of Medical Sciences, Tehran, Iran. 6Department of
Pediatric Nephrology, The Children’s Hospital Medical Center, Faculty of Medicine, Tehran University of
Medical Sciences, Tehran, Iran. 7Department of Occupational Health Engineering, Faculty of Public Health,
Tehran University of Medical Sciences, Tehran, Iran. 8Department of Pediatric Nephrology, Atieh Hospital,
Tehran, Iran.

Abstract
Background: Normal standard references of blood pressure (BP) for children and adolescents have
been suggested to be constructed based on anthropometric indices. Accordingly, we aimed to develop
first BP reference percentiles by weight and age for Iranian children aged 3-18 years old.
Materials and Methods: A total of 16,246 children and adolescents aged 3-18 years were included
from 3 cross-sectional studies conducted in Tehran- Iran. Data on demographic characteristics,
anthropometric indices and BP values of these subjects were gathered. Quantile regression model was
used to assess the need for weight adjustment in different percentiles of systolic and diastolic BPs
with age, gender, and the corresponding weight percentiles. Then, Age- and sex-specific BP
nomograms were developed according to weight.
Results: All the regression coefficients for weight percentiles were statistically significant in quantile
regression of BPs, which confirms the positive effect of adjustment for weight (P<0.05). The BP
percentiles by age and weight are presented for each gender. All the BP percentiles rose steadily in all
the weight percentiles with minor discrepancies between the two genders. Based on the weight-
adjusted BP curves, lean subjects are estimated to have a higher prevalence of hypertension while this
figure is lower among the overweight and obese children.
Conclusion: This study presents the first Iranian BP references by age and weight for 3 to 18 year old
children and adolescents. BMI-adjusted BP curves were found to be a better tool for assessing the
prevalence of hypertension in children and adolescents, on the basis of which a more reliable
classification standard for hypertension could be obtained.
Key Words: Blood Pressure, Children, Nomograms, References, Weight.

*Please cite this article as: Hosseini M, Baikpour M, Yousefifard M, Yaseri M, Fayaz M, Shirafkan H, et al.
Blood Pressure Nomograms by Age and Weight for Iranian Children and Adolescents. Int J Pediatr 2016; 4(7):
2153-66.

*Corresponding Author:
Neamatollah Ataei,MD , Department of Pediatric Nephrology, The Children’s Hospital Medical Center, Faculty
of Medicine, Tehran University of Medical Sciences, Tehran, Iran. Address: Dr. Gharib St., Azadi Avenue,
14194 Tehran, Iran.
Email: mhossein110@yahoo.com
Received date Feb23, 2016; Accepted date: Mar 22, 2016

Int J Pediatr, Vol.4, N.7, Serial No.31, Jul 2016 2153

Blood Pressure Nomograms for Iranian Children

1- INTRODUCTION and included all the age range of childhood

and adolescence (22). Only BP percentiles
Approximately, 13.5% of the premature
by age and height were presented in their
deaths and 6% of the total global
study, but since the correlation of BP has
Disability Adjusted Life Year is attributed
been found to be stronger with weight and
to hypertension which is regarded as one
body mass index (BMI) rather than height
of the most prevalent risk factors of
(23-25), for the first time in Iran, we aimed
cardiovascular diseases (1). Accordingly
to develop BP percentiles by weight for
high blood pressure (BP) among adults and
these age groups.
children has drawn major attention and this
health issue is considered as a priority for
2- MATERIALS AND METHODS
the health-care systems all around the
world. Hypertension is associated with 2-1. Study design
various complications which can be The present study was performed based
controlled with early detection and on data gathered from three surveys
treatment of the patients, therefore blood conducted during 2000 to 2010 in Tehran,
pressure measurement is now established the capital city of Iran. The protocol of the
as an integral part of routine physical study was approved by the Ethics
examinations (2). Committee of Tehran University of
Cardiovascular accidents most commonly Medical Sciences and principles of the
occur in patients older than fifty years; Helsinki declaration were followed
however, epidemiologic and throughout the survey.
pathophysiologic evidence suggest that 2-2. Study Population
high blood pressure and other risk factors
of cardiovascular disease develop from A total of 16,246 children and adolescents
childhood (3). Furthermore, a strong aged 3 to 18 years old were included in
relation has also been found between high this study, a sample population chosen
levels of blood pressure in childhood and from Tehran previously shown to be
adulthood hypertension (4-6). In this representative of the entire Iranian (26,
regard, many researchers have aimed to 27). In one of these studies, it was shown
assess blood pressure trends in children that standard body mass index percentiles
and adolescents. drawn based on data from Tehran did not
show a significant difference with standard
On another note, BP has been observed to curves drawn based on data from the entire
vary among different ethnicities and races country (27). Data gathered by three cross-
(7-10) and so standard nomograms derived sectional studies were combined to make
from one population might not be our sample population. Randomized
applicable for others and local data should sampling of all these three surveys had
be referred to instead (9-12). Accordingly, been carried out from 20 different districts
BP nomograms for children and of Tehran. Conducted during November
adolescents up to the age of 18 are 2000 to November 2002, the first survey
presented by the United States’ Task Force included 8,848 primary school children
on BP Control in Children (13-15). Similar aged 7 to 12 years old. The second study
reference data have been presented by was carried out in 2004 and sampled 6,017
other countries as well (7, 8, 10, 16, 17). children and adolescents aged 12 to 18
Few studies have developed references of years old from secondary and high
systolic and diastolic BPs for children and schools. The last study applied a 2-stage
adolescents in Iran (18-21), of which only cluster sampling method in 2010 to include
the study of Ataei et al. was representative 2,107 subjects which comprised of 1
for the whole population of the country

Int J Pediatr, Vol.4, N.7, Serial No.31, Jul 2016 2154

Hosseini et al.

month to 2 years old infants and 2 to 7 be free for auscultation. Systolic and
years old children from kindergartens (28). diastolic BPs were recorded based on
Due to low sample size in ages 1 month to Korotkoff sounds (the K1 sound for
2 years old, in the present study, we systolic BP, the K4 and K5 sounds for
included children and adolescents aged 3- diastolic BP of 3-12 year olds and K5 for
18 years old. 13-18 year old children, respectively). The
A child with a normal general appearance, mean of two consecutive BP
no documented underlying disease, no measurements, measured at least 30
history of cardiovascular disorders and no seconds apart, was calculated for each
history of antihypertensive drug use was subject.
regarded as a healthy child, which was
2-4. Statistical analysis
established as the inclusion criterion for
this study. Detailed explanations of the 2-4-1. Age-gender-specific percentile
sampling methods are presented in our values
previous articles (19, 28, 29). Briefly, 20 To assess the correlation between weight,
districts were selected based on municipal blood pressure and age, the age-sex-
districts of Tehran. In each district, 1 all- specific normal deviations of weight was
girls school and 1 all-boys school were calculated. Then, the computed normal
randomly selected from the schools listed deviation was mounted in the standard
by Tehran education office. In each school, normal distribution and the corresponding
all the students were studied. percentile value was calculated to develop
Data were collected by the trained interns the age-sex-specific percentile values of
of the medical center. The parents or weight.
guardians of the subjects signed an 2-4-2. Construction of the BP
informed written consent prior to nomograms according to age, gender
inclusion. and weight
2-3. Measurements BP percentiles were presented as a
Weight measurements were done by a function of age and weight through
group of trained field technicians in each construction of two gender-specific
administrative district. A SECA scale separate models for systolic BP and
(USA, model 760) was used to weigh diastolic BP. First, the weight percentiles
children aged 3 to 6 years old with an were modeled with age for both genders
accuracy of 500 grams. School-aged using latent moderated structural (LMS)
children were weighed without shoes and equations method (30). Then an extension
heavy outer clothing via a daily calibrated of this method developed for two
SECA balanced scale (Germany, model covariates was used to simultaneously fit
710). Detailed descriptions of the BP the reference curves for by age and weight.
massurments are presented in previous The free R 2.15.2 statistical software
studies (22). Briefly, BP was measured via (http://www.R-project.org) was used to fit
a standard mercury sphygmomanometer the Generalized Additive Models for
(Model 1002/ Presameter, Riester, Location Scale and Shape (GAMLSS)
Germany) with the child awake, after at with the Box-Cox-Cole-Green distribution
least 5 minutes rest in a comfortable sitting family (31-33). The modeling procedure is
position. The cuff was chosen in a way further explained in the study of Ataei et
that its bladder covered 80%–100% of the al. (22). The goodness of fit was assessed
right arm circumference and its width through evaluating the generalized Akaike
covered approximately 40% the arm information criterion and the proportion of
length, so that the antecubital fossa would data outside the smoothed percentiles.

Int J Pediatr, Vol.4, N.5, Serial No.29, May 2016 2155

Blood Pressure Nomograms for Iranian Children

Moreover, to assess the effect of weight on than 0.001, which confirms the positive
diagnosis of hypertension, the prevalence effect of adjustment for weight. BP
of hypertension was calculated in three percentiles for boys and girls according to
groups of lean, average, and overweight age and weight are presented in Tables.3
and obese children (<25th, 25th-75th, and and 4. The 5th, 10th, 25th, 50th, 75th,
>75th percentiles of BMI, respectively) 90th and 95th percentiles of weight are
using the 95th percentile of weight given in kilograms. As can be seen, all the
adjusted BP references and the figures SBP percentiles rose steadily in all the
were then compared to the method weight percentiles of both genders. In
proposed by the Fourth Report on the earlier ages, the SBP values among boys
Diagnosis, Evaluation, and Treatment of are slightly higher than girls, but the
High Blood Pressure in Children and differences decrease in a way that the
Adolescents criteria, that applies the 95th figures approximate each other in the two
percentile of unadjusted BP references genders and stay steady from the age 5
(34). Finally, the fitted percentile curves through 12 years old.
were compared with the reference values After the age of 12 the curves diverge
developed by USA (13), Germany (17), again and the values among boys rise
Turkey (10), Great Britain (8), China (16), persistently while the increasing trend of
and Saudi Arabia (7). SBP values among girls slows down. DBP
values among girls were slightly higher
3- RESULTS
than boys before the age of 5, and from
A total of 8,381 (51.59%) boys and that point on through the age of 8 the
7,865 (48.41%) girls aged 3–18 years were values were nearly similar in both genders.
included and their BPs and weights were The curves start to part again from the age
measured. Demographic characteristics of of 8 and the DBP percentiles for girls
the included subjects are presented in remain higher than the values for boys
Table. 1. As demonstrated, in all age with smaller divergences compared to SBP
groups the mean of weight and height for curves. The prevalence of hypertension
boys was higher than girls. The estimated based on the standard curves of
discrepancies between the two BP adjusted by anthropometric indices is a
measurements of BP were not significant better indicator of this disorder in the
(P>0.05). The average of absolute population. Therefore, we aimed to
differences for boys ranged from 0.22 to estimate the prevalence of hypertension
1.48 mmHg and among girls varied from based on weight-adjusted BP values in the
0.3 to 1.58 mmHg. Accordingly, the three BMI categories. The figures using
average of the two values for each subject the US references presented in the fourth
was calculated and included in the task force report for subjects with BMIs in
analysis. The mean of diastolic and the <25th, 25th-85th, and >85th percentiles
systolic BPs for boys was higher than girls, were calculated to be 3.56, 7.0 and 12.90%
in almost all the age groups, except for the for girls and 3.10, 3.85, and 10.17% for
SBP in age group of 7-12 years where girls boys, respectively. But using weight-
present with a slightly higher average. adjusted BP percentiles, the prevalence of
Quantile regression models were utilized hypertension for the mentioned BMI
for different percentiles of BPs with age, categories were found to be 8.08, 8.35, and
gender and the corresponding weight 6.91% for girls and 9.76, 6.60, and 7.80%
percentile to assess the need for weight for boys, respectively. As can be seen, the
adjustment. As presented in Table.2, the prevalence of hypertension was estimated
P- values calculated were found to be less to be higher among the lean subjects and

Int J Pediatr, Vol.4, N.7, Serial No.31, Jul 2016 2156

Hosseini et al.

lower, among the overweight and obese weight decreased the false negative cases
children when the weight-adjusted in lean subjects and false positive cases
standard curves of BPs are used instead of among overweight and obese children and
unadjusted BP references. Therefore, adolescents (Figure.1).
adjustment of these curves according to

Table-1: Baseline characteristics of the included children and adolescents (8381 boys and 7865 girls
aged 3–18 years)
Age groups (year)
Subjects’ characteristics
3-6 7-12 13-18
Number of children
Boys 746 4505 3130
Girls 635 4698 2532
Mean (±standard deviation) of weight (kg)
Boys 16.96 (4.06) 29.50 (8.38) 58.33 (15.15)
Girls 15.86 (3.50) 27.73 (7.92) 48.28 (11.51)
Mean (±standard deviation) systolic blood pressure
(mmHg)
Boys 93.56 (10.24) 107.24 (8.98) 115.35 (11.51)
Girls (10.61)
91.50 (8.79) 107.45 (8.90) (11.72)
108.97 (10.66)
Mean (±standard deviation) diastolic blood pressure (10.61) (11.72)
(mmHg)
Boys 55.35 (9.61) 63.69 (9.49) 72.41 (7.87)
Girls (10.61)
54.41 (8.48) (10.61)
63.34 (9.57) (11.72)
71.21 (9.11)
(10.61) (10.61) (11.72)

Table-2: Estimated quintile regression for blood pressure measurements according to age and weight
percentile and gender
25th 50th 75th / 85th 95h
Parameters
Coeff (±SE) P-value Coeff (±SE) P-value Coeff (±SE) P-value Coeff (±SE) P-value
Systolic Blood Pressure
Age (years) 1.34 (±0.03) <0.001 1.42 (±0.02) <0.001 1.53 (±0.02) <0.001 1.87 (±0.03) <0.001
Gender -1.49 (±0.21) <0.001 -1.45 (±0.17) <0.001 -1.00 (±0.17) <0.001 0.05 (±0.25) 0.84
0.08 (±0.003) 0.07 (±0.003) 0.06 0.09 (±0.004)
Weight (Percentile) <0.001 <0.001 <0.001 <0.001
(±0.003)
Intercept 84.7 (±0.40) <0.001 90.9 (±0.30) <0.001 95.6 (±0.29) <0.001 96.9 (±0.40) <0.001
R2 0.1467 0.1569 0.1892 0.2428
Diastolic Blood Pressure

Age (years) 1.50 (±0.03) <0.001 1.42 (±0.02) <0.001 1.43 (±0.02) <0.001 1.53 (±0.03) <0.001
Gender 0.14 (±0.21) 0.495 0.04 (±0.18) 0.849 0.04 (±0.12) 0.001 1.13 (±0.18) <0.001
0.06 (±0.003) 0.06 (±0.003) 0.04 0.04 (±0.003)
Weight (Percentile) <0.001 <0.001 <0.001 <0.001
(±0.002)
Intercept 41.7 (±0.37) <0.001 48.9 (±0.32) <0.001 54.2 (±0.20) <0.001 57.7 (±0.33) <0.001
R 2 0.1688 0.1780 0.2104 0.2428

R2: Coefficient of determination; SE: Standard error; All coefficients (Coeff) for weight percentiles are
statistically significant at P < 0.001.

Int J Pediatr, Vol.4, N.5, Serial No.29, May 2016 2157

Blood Pressure Nomograms for Iranian Children

Table- 3: Blood pressure values for boys according to age and weight
SBP (mm Hg) DBP (mm Hg)
Age Weight 50th 50th
(Year) (kg) 90th 95th 99th 90th 95th 99th
Percentile Percentile
Percentile Percentile Percentile Percentile Percentile Percentile
(Median) (Median)
3 8.4 81 90 92 97 48 57 59 63
3 9 82 91 93 97 48 57 59 63
3 10.1 83 92 94 99 49 58 60 64
3 11.4 84 94 96 101 49 58 60 64
3 12.9 86 95 98 103 50 59 61 65
3 14.4 88 97 100 104 50 60 62 66
3 15.3 89 98 101 106 51 60 62 67
4 10.2 86 96 98 103 51 60 62 66
4 10.9 87 96 99 104 51 60 63 67
4 12.2 88 98 100 105 52 61 63 67
4 13.8 90 100 102 107 52 62 64 68
4 15.6 92 101 104 109 53 62 65 69
4 17.5 93 103 106 111 54 63 66 70
4 18.8 94 105 108 113 54 64 66 70
5 11.9 91 101 103 108 53 63 65 69
5 12.7 91 101 104 109 54 63 65 69
5 14.1 93 103 105 110 54 64 66 70
5 16 94 104 107 112 55 64 67 71
5 18.2 96 106 109 114 56 65 68 72
5 20.5 98 108 111 117 57 66 69 73
5 22.1 99 110 113 118 57 67 69 74
6 13.5 94 105 107 112 56 65 67 71
6 14.4 95 105 108 113 56 65 68 72
6 16 96 107 109 114 57 66 68 72
6 18.1 98 108 111 116 57 67 69 73
6 20.7 100 110 113 118 58 68 70 74
6 23.4 101 112 115 121 59 69 71 76
6 25.3 103 114 117 122 60 69 72 76
7 15.1 98 108 111 116 58 67 69 73
7 16 98 109 111 117 58 67 70 74
7 17.8 99 110 113 118 59 68 70 74
7 20.1 101 111 114 120 59 69 71 75
7 23.1 102 113 116 122 60 70 72 77
7 26.3 104 115 118 124 61 71 73 78
7 28.5 106 117 120 125 62 72 74 79
8 16.7 100 111 114 119 59 69 71 75
8 17.7 101 111 114 119 60 69 71 76
8 19.7 102 112 115 121 60 70 72 76
8 22.3 103 114 117 122 61 70 73 77
8 25.6 105 116 119 124 62 71 74 78
8 29.3 107 118 121 126 63 73 75 80
8 32 108 119 122 128 64 74 76 81
9 18.6 103 113 116 121 61 70 73 77
9 19.7 103 114 117 122 61 71 73 77
9 21.9 104 115 118 123 62 71 74 78
9 24.9 105 116 119 125 63 72 74 79
9 28.6 107 118 121 127 64 73 76 80
9 32.9 109 120 123 129 65 74 77 81
9 36 110 121 124 130 66 75 78 82
10 20.8 104 115 118 124 63 72 74 78
10 22.1 105 116 119 124 63 72 74 79
10 24.5 106 117 120 125 64 73 75 79
10 27.9 107 118 121 127 64 74 76 80
10 32.1 109 120 123 128 65 75 77 81
10 37 110 122 125 130 67 76 79 83
10 40.7 111 123 126 132 67 77 80 84
11 23.4 106 117 120 125 64 73 76 80
11 24.8 106 117 120 126 65 74 76 80
11 27.6 107 118 121 127 65 74 77 81
11 31.4 108 120 123 128 66 75 77 82
11 36.2 110 121 124 130 67 76 79 83
11 41.9 112 123 126 132 68 78 80 84
11 46 113 124 127 133 69 79 81 85
12 26.3 107 118 121 126 66 75 77 81
12 28 108 119 122 127 66 75 77 81
12 31.1 109 120 123 128 67 76 78 82
12 35.4 110 121 124 129 68 77 79 83

Int J Pediatr, Vol.4, N.7, Serial No.31, Jul 2016 2158

Hosseini et al.

12 41 111 122 125 131 69 78 80 84

12 47.5 113 124 127 133 70 79 81 86
12 52.3 114 125 129 134 71 80 82 87
13 29.7 108 119 122 128 67 76 78 82
13 31.5 109 120 123 128 68 76 79 83
13 35.1 110 121 124 129 68 77 79 83
13 40.1 111 122 125 131 69 78 80 84
13 46.4 112 124 127 132 70 79 81 86
13 53.9 114 125 128 134 71 80 83 87
13 59.4 115 126 130 135 72 81 84 88
14 33.3 109 120 123 129 69 78 80 84
14 35.4 110 121 124 129 69 78 80 84
14 39.5 111 122 125 130 70 78 81 85
14 45.1 112 123 126 132 71 79 82 86
14 52.3 114 125 128 134 72 80 83 87
14 60.7 115 127 130 136 73 82 84 88
14 67 116 128 131 137 74 83 85 89
15 36.9 111 121 124 130 71 79 81 85
15 39.3 111 122 125 131 71 79 81 85
15 43.9 112 123 126 132 71 80 82 86
15 50.3 114 125 128 133 72 81 83 87
15 58.4 115 127 130 135 73 82 84 88
15 67.9 117 129 132 137 74 83 85 89
15 74.8 118 130 133 139 75 84 86 90
16 40.5 112 123 126 131 72 80 82 86
16 43.2 113 124 127 132 72 80 83 87
16 48.4 114 125 128 134 73 81 83 87
16 55.5 115 127 130 135 73 82 84 88
16 64.5 117 129 132 138 74 82 85 89
16 75 119 131 134 140 75 83 86 90
16 82.7 121 132 136 142 76 84 87 91
17 44.1 113 124 127 133 73 81 83 87
17 47.1 114 125 128 134 73 82 84 88
17 52.8 116 127 130 136 74 82 84 88
17 60.6 118 129 132 138 74 82 85 89
17 70.6 120 132 135 141 75 83 85 89
17 82.1 122 134 138 144 76 84 86 90
17 90.6 124 136 139 145 76 85 87 91
18 47.6 115 126 129 135 74 82 84 88
18 50.8 116 127 131 136 75 83 85 88
18 57.1 118 130 133 138 75 83 85 89
18 65.7 121 132 135 141 75 83 85 89
18 76.6 124 136 139 145 76 84 86 90
18 89.2 127 139 142 148 76 84 86 90
18 98.4 129 141 144 151 76 85 87 91
Weight in kilograms for each age represents the 5th, 10th, 25th, 50th, 75th, 90th, and 95th percentile.

Table 4: Blood pressure values for girls according to age and weight
SBP (mm Hg) DBP (mm Hg)
Age Weight 50th th th th 50th
(Year) (kg) 90 95 99 90th 95th 99th
Percentile Percentile
Percentile Percentile Percentile Percentile Percentile Percentile
(Median) (Median)
3 7.4 81 89 92 96 47 55 57 61
3 8 81 90 92 97 47 56 58 61
3 9.1 82 91 94 98 48 56 58 62
3 10.4 83 92 95 99 49 57 59 63
3 11.9 85 94 96 101 50 58 60 64
3 13.5 86 96 98 103 51 59 62 65
3 14.5 87 97 99 104 51 60 62 66
4 8.7 86 95 97 102 50 58 60 64
4 9.3 86 96 98 103 50 59 61 65
4 10.6 87 97 99 104 51 59 62 66
4 12.1 89 98 101 105 52 60 63 67
4 14 90 100 102 107 53 62 64 68
4 16 92 101 104 109 54 63 65 69
4 17.3 93 102 105 110 54 64 66 70
5 10 90 100 103 107 52 61 63 67
5 10.8 91 100 103 108 53 61 64 68
5 12.2 92 101 104 109 53 62 65 69
5 14.1 93 103 106 111 54 63 66 70
5 16.3 94 105 107 113 55 64 67 71

Int J Pediatr, Vol.4, N.5, Serial No.29, May 2016 2159

Blood Pressure Nomograms for Iranian Children

5 18.7 96 106 109 114 56 66 68 72

5 20.3 97 108 110 116 57 67 69 73
6 11.5 94 104 107 112 55 63 66 70
6 12.4 95 105 108 113 55 64 66 70
6 14.1 96 106 109 114 56 65 67 71
6 16.3 97 107 110 115 57 66 68 72
6 18.9 98 109 112 117 58 67 69 74
6 21.7 100 111 114 119 59 68 71 75
6 23.7 101 112 115 120 60 69 72 76
7 13.2 98 108 111 116 57 66 68 72
7 14.2 98 109 111 117 57 66 68 73
7 16.1 99 109 112 118 58 67 69 74
7 18.6 100 111 114 119 59 68 70 75
7 21.7 102 112 115 121 60 69 72 76
7 25 103 114 117 123 61 71 73 78
7 27.3 104 116 119 124 62 72 74 79
8 15.1 101 111 114 120 59 68 70 74
8 16.2 101 112 115 120 59 68 71 75
8 18.3 102 113 116 121 60 69 71 76
8 21.2 103 114 117 123 61 70 73 77
8 24.7 104 115 119 124 62 71 74 78
8 28.5 106 117 120 126 63 73 75 80
8 31.2 107 118 122 127 64 74 76 81
9 17.2 103 114 117 123 60 70 72 76
9 18.4 103 114 117 123 61 70 73 77
9 20.8 104 115 118 124 62 71 73 78
9 24 105 116 119 125 63 72 75 79
9 28 107 118 121 127 64 73 76 80
9 32.4 108 120 123 129 65 75 77 82
9 35.5 109 121 124 130 66 76 78 83
10 19.5 105 116 119 125 62 72 74 78
10 20.9 105 116 119 125 63 72 74 79
10 23.6 106 117 120 126 63 73 75 80
10 27.2 107 118 121 127 64 74 76 81
10 31.7 108 120 123 129 65 75 78 82
10 36.8 110 121 125 131 67 77 79 84
10 40.3 111 123 126 132 67 77 80 85
11 22.2 106 117 120 126 64 73 76 80
11 23.8 107 118 121 127 64 74 76 81
11 26.8 107 118 122 127 65 75 77 81
11 30.8 108 119 123 129 66 76 78 83
11 35.9 109 121 124 130 67 77 80 84
11 41.6 111 123 126 132 68 78 81 85
11 45.6 112 124 127 133 69 79 82 86
12 25.2 107 118 121 127 66 75 77 82
12 26.9 107 119 122 127 66 76 78 82
12 30.2 108 119 122 128 67 76 79 83
12 34.7 109 120 123 129 68 77 80 84
12 40.4 110 122 125 131 69 79 81 86
12 46.7 112 123 127 133 70 80 83 87
12 51.3 113 125 128 134 71 81 83 88
13 28.3 107 119 122 128 67 77 79 83
13 30.2 108 119 122 128 68 77 80 84
13 33.9 108 120 123 129 68 78 80 85
13 38.8 109 121 124 130 69 79 82 86
13 45 111 122 125 131 70 80 83 87
13 52 112 124 127 133 71 82 84 89
13 57 114 125 129 135 72 82 85 90
14 31.5 108 119 122 128 69 78 81 85
14 33.6 108 119 122 128 69 79 81 85
14 37.5 109 120 123 129 70 79 82 86
14 42.8 110 121 124 130 71 81 83 88
14 49.5 111 123 126 132 72 82 84 89
14 57 113 125 128 134 73 83 86 90
14 62.4 114 126 130 136 74 84 86 91
15 34.6 108 119 122 128 70 79 82 86
15 36.8 108 119 123 128 70 80 82 87
15 40.9 109 120 123 129 71 81 83 88
15 46.5 110 121 125 131 72 82 84 89
15 53.5 112 123 126 132 73 83 86 90
15 61.4 114 125 129 135 74 84 87 92
15 67 115 127 130 137 75 85 88 92
16 37.5 108 119 122 128 71 80 83 87

Int J Pediatr, Vol.4, N.7, Serial No.31, Jul 2016 2160

Hosseini et al.

16 39.7 108 120 123 129 72 81 83 88

16 43.9 109 121 124 130 72 82 84 89
16 49.7 111 122 125 131 73 83 86 90
16 56.8 112 124 127 133 75 84 87 92
16 64.9 114 126 130 136 76 86 88 93
16 70.6 116 128 131 138 76 86 89 94
17 40 108 119 123 128 72 82 84 88
17 42.2 109 120 123 129 73 82 85 89
17 46.5 110 121 124 130 74 83 86 90
17 52.3 111 123 126 132 75 84 87 91
17 59.5 113 125 128 134 76 86 88 93
17 67.5 115 127 131 137 77 87 90 94
17 73.2 117 129 133 139 78 88 90 95
18 42.4 109 120 123 129 73 83 85 89
18 44.6 109 121 124 129 74 83 86 90
18 48.9 110 122 125 131 75 84 87 91
18 54.6 112 124 127 133 76 86 88 93
18 61.7 114 126 129 135 77 87 90 94
18 69.5 117 129 132 138 79 88 91 96
18 75 119 131 134 141 79 89 92 97
Weight in kilograms for each age represents the 5th, 10th, 25th, 50th, 75th, 90th, and 95th percentile.

Fig.1: Prevalence of hypertension based on unadjusted blood pressure (BP) and weight-
adjusted BP, for lean (<25th), average (25th-75th) and overweight and obese (>75th) children
and adolescent base on body mass index (BMI) categories.

Int J Pediatr, Vol.4, N.5, Serial No.29, May 2016 2161

Blood Pressure Nomograms for Iranian Children

4- DISCUSSION Furthermore, the prevalence of

hypertension was calculated based on
Considering its high prevalence and its
different references and among various
various complications that lead to high
groups of the study population considering
morbidity and mortality rates,
the BMIs of boys and girls. The overall
hypertension is regarded as a major public
prevalence of hypertension based on US
health issue worldwide (29). Since
references (6.91% for girls and 5.67 for
hypertension in adults is correlated with
boys) was lower than the prevalence
childhood BP levels, many studies have
estimated based on Iranian weight-adjusted
focused on developing normal standard
references (8.12% for girls and 8.38% for
references of BP for children and
boys). Based on the standard curves of BP
adolescents according to their age, gender,
constructed according to weight, the
and anthropometric indices (14, 16, 35).
prevalence of hypertension came up higher
For example the American Academy of
among the lean subjects and lower in the
Pediatrics Task Force on Blood Pressure
overweight and obese population,
developed standard references of BP levels
decreasing the chance of false judgments
according to age and height from birth to
on the BP measurements.
18 years (13, 14, 36). In another study
Neuhauser et al. (37) performed advanced To compare our results with the USA (13),
statistical analyses on the data collected in Germany (17), Turkey (10), Great Britain
the German Health Interview and (8), China (16), and Saudi Arabia (7)
Examination Survey for Children and surveys, we derived the corresponding data
Adolescents (KiGGS 2003-2006) (38) and on the ages of 3 to 18 years from these
developed standard BP references for non- studies. For the information to be
overweight, children and adolescents of comparable, only data from the 50th
Germany aged 3 to 17 years old. The data percentile of height from the German and
presented in this study is the first BP American references and the 50th
reference developed by age and weight for percentile of weight from ours were
Iranian children and adolescents. In included. The 95th percentiles of BP by age
previous surveys conducted in other for all the 7 mentioned surveys are
countries the standard curves of BP were depicted in Figure.2.
only drawn by age and gender. For As illustrated, the SBP rose with age in a
example Tumer et al. included 5,599 progressive manner among both genders,
Turkish infants and children under 18 with the rise being steeper among boys
years old (10) and developed normal BP after the age of 13. Slight differences were
curves based on the gathered information. observed between DBP curves of both
Jackson et al. (8) derived BP centiles boys and girls.
according to the data collected from The highest SBP levels are the Great
22,901 children aged 4 to 23 years old in Britain’s and Saudi Arabia’s. Minor
Great Britain. In another survey conducted differences can be observed between these
in Saudi Arabia, Al Salloum et al. (7) two curves up to the age of 13, where their
assessed 16,226 infants, children and curves start to diverge and the Great
adolescents under 18 years of age and Britain stays ahead. Up to the age of six,
developed BP reference percentiles. Mi et Iranian curve is the lowest for both
al. (16) also included data from eleven genders. From that age on, although our
large-scale cross sectional surveys in BP levels are not the lowest of all but they
China evaluating 112,227 children and are among the 2 or 3 lowest curves
adolescents aged 3 to 18 years old to presented.
construct BP references.

Int J Pediatr, Vol.4, N.7, Serial No.31, Jul 2016 2162

Hosseini et al.

As for the DBP, the highest curve belongs among other curves till it becomes the
to Saudi Arabia in almost all the ages for lowest curve after the age of 9 years old.
both genders, except among girls older One of the main strengths of our study is
than 15 years where Iranian curve exceeds the large sample population which is
theirs. Overall Iranian DBP curve presents nationally representative and covers a wide
with the steepest slope in a way that up to range of ages. Standardized measurements
the age of 7, Iranian curve is among the of BP and anthropometric indices, using a
two lowest curves but it increases to BP measuring device suitable for children,
become the highest among girls and the measuring BPs twice for each subject and
second highest among boys after the age of the simultaneous modeling by age and
15. Great Britain’s DBP curve presents weight with advanced statistical methods
with the mildest slope, downgrading could be considered as other strengths of
the present survey.

Fig.2: Comparison of the 95th percentile of blood pressure values in boys (A) and girls (B) from
several countries. Blood pressure values of American (USA) and German children and adolescents
correspond to the 50th percentile of height. Blood pressure values of Iranian children and
adolescents correspond to the 50th percentile weight.

Int J Pediatr, Vol.4, N.5, Serial No.29, May 2016 2163

Blood Pressure Nomograms for Iranian Children

4-1. Limitations of the study 1. Lawes CM, Hoorn SV, Rodgers A.

Global burden of blood-pressure-related
Since measurements were performed by disease, 2001. The Lancet.
human, our data were susceptible to end- 2008;371(9623):1513-8.
digit preference, i.e. values ending in 0 or
5 were more frequently reported (39). The 2. Somu S, Sundaram B, Kamalanathan
A. Early detection of hypertension in general
goodness of fit criteria were not entirely practice. Arch Dis Child. 2003;88(4):302-.
met and the fitted models changed with the
prevalence of hypertension calculated 3. Raitakari OT, Juonala M, Kähönen M,
based on these curves (40). Taittonen L, Laitinen T, Mäki-Torkko N, et al.
Cardiovascular risk factors in childhood and
Another limitation of the present study is carotid artery intima-media thickness in
defining hypertension based on only 2 adulthood: the Cardiovascular Risk in Young
measurements, which can lead to slight Finns Study. JAMA. 2003;290(17):2277-83.
inaccuracy in estimation of hypertension. 4. Bao W, Threefoot SA, Srinivasan SR,
A person cannot be introduced as Berenson GS. Essential hypertension predicted
hypertensive by 2 BP measurements with a by tracking of elevated blood pressure from
short time interval. However in this study, childhood to adulthood: the Bogalusa Heart
hypertension prevalence was compared Study. Am J Hypertens. 1995;8(7):657-65.
based on weight-adjusted BP and non- 5. Chen X, Wang Y. Tracking of blood
adjusted BP curves. So, the fact that the pressure from childhood to adulthood a
study’s definition of hypertension might be systematic review and meta–regression
inaccurate, does not affect the final analysis. Circulation. 2008;117(25):3171-80.
findings and conclusion, as it has the same 6. Dekkers JC, Snieder H, van den Oord
effect on the diagnostic accuracy of both EJ, Treiber FA. Moderators of blood pressure
standard curves. development from childhood to adulthood: a
10-year longitudinal study. J Pediatr.
5. CONCLUSION 2002;141(6):770-9.
The reference data developed in this study 7. Al Salloum AA, El Mouzan MI, Al
is the first Iranian BP reference by age and Herbish AS, Al Omar AA, Qurashi MM.
weight that covers children and Blood pressure standards for Saudi children
adolescents aged 3 to 18 years old. BMI- and adolescents. Ann Saudi Med.
adjusted BP curves were found to be a 2009;29(3):173-8.
better tool for assessing the prevalence of 8. Jackson LV, Thalange NK, Cole TJ.
hypertension in children and adolescents, Blood pressure centiles for Great Britain. Arch
on the basis of which a more reliable Dis Child. 2007;92(4):298-303.
classification standard for hypertension 9. Jafar TH, Islam M, Poulter N, Hatcher
could be obtained. J, Schmid CH, Levey AS, et al. Children in
6- CONFLICT OF INTEREST: None. South Asia Have Higher Body Mass–Adjusted
Blood Pressure Levels Than White Children in
7- ACKNOWLEDGMENTS the United States A Comparative Study.
Circulation. 2005;111(10):1291-7.
The authors would like to thank all the
children, adolescents and their families for 10. Tümer N, Yalcinkaya F, Ince E, Ekim
their cooperation. This research has been M, Köse K, Cakar N, et al. Blood pressure
supported by Tehran University of nomograms for children and adolescents in
Medical Sciences & health Services grant Turkey. Pediatr Nephrol. 1999;13(5):438-43.
(Grant No 93-02-184-25774). 11. Goonasekera C, Dillon M.
Measurement and interpretation of blood
8- REFERENCES pressure. Arch Dis Child. 2000;82(3):261-5.

Int J Pediatr, Vol.4, N.7, Serial No.31, Jul 2016 2164

Hosseini et al.

12. Arafat M, Mattoo TK. Measurement Study. Eur J Cardiovasc Prev Rehabil.
of blood pressure in children: 2006;13(6):956-63.
recommendations and perceptions on cuff
22. Ataei N, Hosseini M, Fayaz M, Navidi
selection. Pediatrics. 1999;104(3):e30.
I, Taghiloo A, Kalantari K, et al. Blood
13. Horan M. Report of the second Task pressure percentiles by age and height for
Force on Blood Pressure Control in children and adolescents in Tehran, Iran. J
Children―1987. Pediatrics. 1987;79(1):1-25. Hum Hypertens. 2016;30(4):268-77.
14. National High Blood Pressure 23. Hu G, Barengo NC, Tuomilehto J,
Education Program. The fourth report on the Lakka TA, Nissinen A, Jousilahti P.
diagnosis, evaluation, and treatment of high Relationship of physical activity and body
blood pressure in children and adolescents. mass index to the risk of hypertension: a
Pediatrics. 2005;114:255–76. prospective study in Finland. Hypertension.
2004;43(1):25-30.
15. Gifford R, August P, Cunningham G,
Green L, Lindheimer M, McNellis D, et al. 24. Brown CD, Higgins M, Donato KA,
Report of the national high blood pressure Rohde FC, Garrison R, Obarzanek E, et al.
education program working group on high Body mass index and the prevalence of
blood pressure in pregnancy. Am J Obstet hypertension and dyslipidemia. Obes Res.
Gynecol. 2000;183(1):S1-S22. 2000;8(9):605-19.
16. Mi J, Wang T-y, Meng L-h, Zhu G-j, 25. Stamler R, Stamler J, Riedlinger WF,
Han S-m, Zhong Y, et al. Development of Algera G, Roberts RH. Weight and blood
blood pressure reference standards for Chinese pressure: findings in hypertension screening of
children. Chin J Evid Based Pediatr. 1 million Americans. JAMA.
2010;5(1):4-14. 1978;240(15):1607-10.
17. Neuhauser HK, Thamm M, Ellert U, 26. Hosseini M, Carpenter R, Mohammad
Hense HW, Rosario AS. Blood pressure K. Growth charts for Iran. Ann Hum Biol.
percentiles by age and height from 1998;25(3):237-47.
nonoverweight children and adolescents in
27. Hosseini M, Baikpour M, Yousefifard
Germany. Pediatrics. 2011:e978-88.
M, Mansournia MA, Yaseri M, Asady H, et al.
18. Ashrafi M, Abdollahi M, Ahranjani B, Body Mass Index Percentile Curves for 7 To
Shabanian R. Blood pressure distribution 18 Year Old Children and Adolescents; are the
among healthy schoolchildren aged 6-13 years Sample Populations from Tehran Nationally
in Tehran. East Mediterr Health J. 2005;11(5- Representative? Int J Pediatr. 2016;4(6):1926-
6):968-76. 34.
19. Ataei N, Aghamohammadi A, Yousefi 28. Hosseini M, Navidi I, Hesamifard B,
E, Hosseini M, Nourijelyani K, Tayebi M, et Yousefifard M, Jafari N, Ranji Poorchaloo S,
al. Blood pressure nomograms for school et al. Weight, Height and Body Mass Index
children in Iran. Pediatr Nephrol. Nomograms; Early Adiposity Rebound in a
2004;19(2):164-8. Sample of Children in Tehran, Iran. Int J Prev
Med. 2013;4(12):1414-20.
20. Ayatollahi S, Vakili M, Behboodian J,
Zare N. Reference Values for Blood Pressure 29. Ataei N, Aghamohammadi A, Ziaee
of Healthy Schoolchildren in Shiraz (Southern V, Hosseini M, Dehsara F, Rezanejad A.
Iran) using Quantile Regression. Iran Prevalence of hypertension in junior and
Cardiovasc Res J. 2010;4(2):55-65. senior high school children in Iran. Iran J
Pediatr. 2007;17(Suppl 2):237-42.
21. Kelishadi R, Ardalan G, Gheiratmand
R, Majdzadeh R, Delavari A, Heshmat R, et al. 30. Cole TJ, Green PJ. Smoothing
Blood pressure and its influencing factors in a reference centile curves: the LMS method and
national representative sample of Iranian penalized likelihood. Stat Med.
children and adolescents: the CASPIAN 1992;11(10):1305-19.

Int J Pediatr, Vol.4, N.5, Serial No.29, May 2016 2165

Blood Pressure Nomograms for Iranian Children

31. Stanojevic S, Wade A, Stocks J, National High Blood Pressure Education

Hankinson J, Coates AL, Pan H, et al. Program. Pediatrics. 1996;98:649-57.
Reference ranges for spirometry across all
37. Neuhauser HK, Thamm M, Ellert U,
ages: a new approach. Am J Respir Crit Care
Hense HW, Rosario AS. Blood pressure
Med. 2008;177(3):253.
percentiles by age and height from
32. Cole T, Stanojevic S, Stocks J, Coates nonoverweight children and adolescents in
A, Hankinson J, Wade A. Age‐and size‐related Germany. Pediatrics. 2011;127(4):e978-e88.
reference ranges: A case study of spirometry
38. Kamtsiuris P, Lange M, Schaffrath
through childhood and adulthood. Stat Med.
RA. The German Health Interview and
2009;28(5):880-98.
Examination Survey for Children and
33. Rigby R, Stasinopoulos D. Adolescents (KiGGS): sample design,
Generalized additive models for location, scale response and nonresponse analysis.
and shape. J R Stat Soc Ser C Appl Stat. Bundesgesundheitsblatt,
2005;54(3):507-54. Gesundheitsforschung, Gesundheitsschutz.
2006;50(5-6):547-56.
34. Falkner B, Daniels SR. Summary of
the Fourth Report on the Diagnosis, 39. Alsanjari O, de Lusignan S, van
Evaluation, and Treatment of High Blood Vlymen J, Gallagher H, Millett C, Harris K, et
Pressure in Children and Adolescents. al. Trends and transient change in end‐digit
Hypertension. 2004;44(4):387-8. preference in blood pressure recording: studies
of sequential and longitudinal collected
35. Muntner P, He J, Cutler JA, Wildman
primary care data. Int J Clin Pract.
RP, Whelton PK. Trends in blood pressure
2012;66(1):37-43.
among children and adolescents. JAMA.
2004;291(17):2107-13. 40. Wen SW, Kramer MS, Hoey J, Hanley
JA, Usher RH. Terminal digit preference,
36. National Heart Lung Blood Institute.
random error, and bias in routine clinical
Update on the 1987 Task Force Report on
measurement of blood pressure. J Clin
High Blood Pressure in Children and
Epidemiol. 1993;46(10):1187-93.
Adlescents: A Work Group Report from the

Int J Pediatr, Vol.4, N.7, Serial No.31, Jul 2016 2166