Applied Nursing Research 31 (2016) 117120

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Applied Nursing Research

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Research Briefs

Child and Maternal Factors That Inuence Child Blood Pressure in

Preschool Children: An Exploratory Study
Marti Rice, PhD, RN, FAAN a,, Anne Turner-Henson, PhD, RN, FAAN a, Na-Jin Park, PhD, RN b,
Andres Azuero, PhD a, Azita Amiri, PhD, RN c, Christine A. Feeley, PhD, RN b, Ann Johnson, MSN, RN, CPNP d,
Thuy Lam, PhD, RN e, Luz Huntington-Moskos, PhD, RN, CPN f,
Jeannie Rodriguez, PhD, RN, C-PNP/PC g, Susan Williams, PhD, RN h
a
University of Alabama at Birmingham School of Nursing, University of Alabama at Birmingham, Birmingham, AL
b
University of Pittsburg School of Nursing, Pittsburg, PA
c
University of Alabama at Huntsville, Huntsville, AL
d
University of Alabama at Birmingham PhD student
e
J. F. Drake State Community and Technical College, Huntsville, AL
f
University of Louisville School of Nursing
g
Emory University Nell Hodgson Woodruff School of Nursing
h
University of South Alabama, College of Nursing

a r t i c l e i n f o a b s t r a c t

Article history: Purpose: Hypertension is a risk factor for cardiovascular disease (CVD) in adults and children and has its origins in
Received 16 March 2015 childhood. While the prevalence of hypertension in children is estimated to be 2 to 5%, instance elevations in
Revised 17 January 2016 blood pressure readings (BPRs) in school-age children and adolescents are more common, track to adulthood,
Accepted 18 January 2016 and are an independent risk factor for CVD. Less information is available about BPR in the preschool period
and what child factors could inuence those BPR. The primary aims of this exploratory study were to determine
Keywords:
child blood pressure (BP) levels and determine effect sizes of the relationships between child and maternal fac-
Blood pressure
Preschool
tors that can inuence child BP.
Inuencing factors Methods: A convenience sample of 15 rural and 15 urban children enrolled in Head Start programs (13 males; 14
females; all black) with ability to understand and speak English and with mothers who gave consent and could
understand, read and speak English were enrolled. Mothers completed demographic information about their
child including, gender, birth history and age. Height, weight, waist circumference and BP were measured in
the mothers and the children. Children gave saliva specimens for cortisol and C-reactive protein.
Results: Over 37% of the children had elevated BPR with over 20% at or above the 95th percentile. Effect sizes of
relationships ranged from very small to large.
Conclusion: Elevations in BPR may be seen as early as preschool. It is important to examine factors, both child and
maternal that inuence BP.
2016 Elsevier Inc. All rights reserved.

An estimated 80 million adults and 2 to 3 million children in the US
have hypertension (Mozaffarian et al., 2015; Rosner, Cook, Daniels, &
Falkner, 2013). Diagnosed hypertension in children is rising (Hansen,
Gunn, & Kaelber, 2007), but is surpassed by elevations in blood pressure
readings (BPR) without diagnosed hypertension, particularly in school-
age children and adolescents (Rosner et al., 2013). Elevated BPR on even
one occasion are concerning in that they can track to adulthood (Gauer
& Qiu, 2012) and are an independent risk factor for cardiovascular disease
Corresponding author at: University of Alabama at Birmingham, 1720 2nd Ave. So.,
Birmingham, Al, 35294. Tel.: +1 205 975 7802; fax: +1 205 996 7183.
E-mail address: schauf@uab.edu (M. Rice).
(Daniels, 2012). Few studies (Shapiro, Hersh, Caban, Sutherland, & Patel,
2012; Williams, Strobino, Bollella, & Brotanek, 2004) have examined
BPR in the preschool period (ages 3-5 years) and none have examined
what factors, both child and maternal, could inuence these readings.
Child factors such as weight and weight distribution (body mass
index (BMI), waist circumference (WC)) (Leung et al., 2011; Rosner
et al., 2013) gender (Rosner et al., 2013), birth status (pre-term/term)
(Zhang, Kris-Etherton, & Hartman, 2014), socioeconomic status (SES)
(Mozaffarian et al., 2015) and stress response (salivary cortisol levels)
(Dowd, Simanek, & Aiello, 2009) are known to inuence BP in
older children and adolescents. More recently, systemic inammation
(C-reactive protein (CRP)) has been considered and is thought to be
the underlying mechanism for BP elevations (Brown et al., 2010;

http://dx.doi.org/10.1016/j.apnr.2016.01.008
0897-1897/ 2016 Elsevier Inc. All rights reserved.
118 M. Rice et al. / Applied Nursing Research 31 (2016) 117120

Hage, 2014). The location of the childs residence (rural or urban), can Program Working Group on High Blood Pressure in Children and Ado-
also differentially inuence BPR (Grotto, Huerta, & Sharabi, 2008; U.S. lescents, 2004). Data about child age, gender, and birth were obtained
Department of Agriculture, 2013). Evidence indicates that those living from the mothers. Height for mother and child was measured in inches
in rural areas have less access to care (Harris, Aboueissa, Baugh, & using a portable stadiometer (Heyward & Wagner, 2004), while weight
Sarton, 2015), higher poverty (U.S. Department of Agriculture, 2013), was measured in pounds by a standard balance beam scale. BMI for both
and lower educational attainment (U.S. Department of Agriculture, mother and child was deterhe/height in meters squared (Centers for
2013); all factors that can inuence BP. Disease Control & Prevention). WC for both mother and child was mea-
Maternal factors, such as BMI, WC, and BP have also been associated sured in inches (US Centers for Disease Control and Prevention, 2007)
with child BP (Malbora et al., 2010). These associations may be a reec- and compared to WC references for children (Fernandez, Redden,
tion of genetic determinants and/or environmental inuences (Cui, Pietrobelli, & Allison, 2004) and adults (Fryar, Gu, & Ogden, 2012). Sali-
Hopper, & Harrap, 2002). Among the inuences in the environment vary samples were used to measure cortisol and CRP. Specimens were
that can inuence BP are socioeconomic status, maternal educational at- collected at approximately the same time of the day (10:00
tainment, stress, industrial pollution, and tobacco exposure (Braveman 10:30 AM, one hour after breakfast) to minimize the potential inuence
& Gottlieb, 2014). of circadian variability. Saliva samples were assayed for cortisol and CRP
The purposes of this pilot study were to: 1) determine BP levels of by ELISA immunoassay (Salimetrics, 2014).
preschool children enrolled in rural and urban Head Start (HS) pro- Data were analyzed by computing frequencies on categorical vari-
grams and 2) determine the effect sizes of the relationships between ables and means on continuous variables. Effect sizes were determined
child (gender, birth status (preterm or term), BMI, WC, cortisol, CRP based on bivariate correlations of child (gender, birth status, BMI, WC,
levels) and maternal factors (BMI, BP, and WC) and child BPR. Eligibility cortisol, CRP levels) and maternal factors (BMI, BP, WC) and child BP
to enroll in HS is limited to those of low SES, dened as family income at percentiles. The reported magnitude of the effect sizes was based on
or below the federal poverty guidelines (U.S. Department of Health & the guidelines described by Cohen (1988) for Pearsons r and Phi coef-
Human Services Administration for Children & Families, 2015). Low cients. Small effect sizes are correlations of .1, medium effect sizes are
SES children were enrolled to control for SES since SES is associated those of .3 and large effect sizes are .5. The relevance threshold was
with elevated BP in older children, adolescents, and adults (Braveman & set at .2 so any observed effect size that did not meet this threshold
Gottlieb, 2014; Expert Panel on Integrated Guidelines for Cardiovascular was considered not likely to be relevant.
Health and Risk Reduction in Children and Adolescents, 2012).
2. Results
1. Methods
A total of 14 female and 13 male black children and their mothers
A convenience sample of 30 children and their mothers were en- participated in this study. Sample characteristics and descriptive statis-
rolled from HS programs in a southeastern rural county (N = 15) and tics for the demographic (age) and study variables (BMI, WC, BP, corti-
urban (N = 15) area. Inclusion criteria for the children included: sol CRP) are included in Table 1. The majority of children (87.3%) were
being 3-5 years of age, able to speak and understand English, and have in the normal or underweight category for BMI with one child being
parental consent. The inclusion criteria for mothers were: be able to overweight and two obese based on the BMI percentiles (US Centers
understand and speak English, complete study questionnaires, and be for Disease Control and Prevention, 2015). Only 1 child had WC at or
willing to provide informed consent. This study was approved by the above the 90 th percentile (Fernandez et al., 2004). Of the children
Institutional Review Board of the rst authors institution. with birth status information, 18 were full term and six were pre-
Two BP measurements (Dinamap PRO 100) taken two minutes apart term. The majority of the CRP and cortisol levels were not elevated.
for both mother and child were assessed in the right arm after a ve The mean SBP percentile was 78; mean DBP percentile was 79.
minute rest period (James et al., 2014; National High Blood Pressure Of the child BP levels, 37.5% (n = 9) of the children in the sample
Education Program Working Group on High Blood Pressure in Children with age, height and gender reported (n = 24) had elevated BPR at or
and Adolescents, 2004). The two measurements of the systolic blood above the 90 th percentile. Of the 9 children (7 females and 2 males)
pressure (SBP) reading and the diastolic blood pressure (DBP) reading with elevated BP, 4 (16.67%) had BPR in the 90th to 94th percentile
were averaged and the average used for analysis. Information from (prehypertension level) and 5 (20.83%) had BPR at or above the 95 th
the Eighth Joint National Committee (James et al., 2014) was used to de- percentile (hypertensive level). Most of the elevations were of SBP.
termine adult percentiles. National pediatric guidelines were used to Over 77% of the children with elevated BPR were normal weight
determine BP percentiles for children based on an algorithm using or underweight.
age, gender and height (National High Blood Pressure Education Pearson correlation coefcients for the child and maternal factors
and associated effect sizes are presented in Table 2. Among the relation-
Table 1 ships with effect sizes that reached the level of relevance were child cor-
Descriptive Statistics for Demographic and Study Variables. tisol and child DBP percentile (large), child CRP and child DBP percentile
Mean Standard Deviation Range (medium), maternal BMI and both child SBP percentile (medium) and
child DBP percentile (small to medium), maternal WC and both child
Child Factors
Ages: 3.9 years .78 3 5 years
SBP percentile (small to medium) and child DBP (medium). Phi Coef-
Body Mass Index: 15.00 3.00 8.4 - 24.18 cients for the relationships between nominal variables and associated
Waist Circumference: 19.92 1.57 17.72 25.69 effect sizes were calculated for child gender and child BP status (normal,
Systolic Blood Pressure: 105 8.03 86-121 prehypertensive, or hypertensive reading) and child birth status and
Diastolic Blood Pressure: 63 4.40 54 69
child BP status. There was a medium to large effect size (.43) of gender
Systolic BP Percentile 78.05 19.03 31.75-99.17
Diastolic BP Percentile 79.18 14.21 37.75-94.24 and child BP status, with girls more likely to have a high BPR. In addition,
Cortisol (mg/L): 0.76 2.66 0.04 12.37 there was a medium effect size (.35) of child birth status with child BP
C Reactive Protein (pg/ml) 9387.06 24811.52 89.98-93295.38 status, with children born preterm more likely to have a high BPR.
Mother Factors
Body Mass Index 32.49 8.20 17.23 52.39 3. Discussion
Waist Circumference 40.47 7.68 28.75 56.06
Systolic Blood Pressure: 119 15.6 84 - 152 Over 37% of the participants in this study had pre-hypertensive or
Diastolic Blood Pressure: 69.75 11.07 49.5 97.5
hypertensive BPR. This nding coincides with those noted in school-
 M. Rice et al. / Applied Nursing Research 31 (2016) 117120
Table 2
Pearson Correlations and Effect Sizes of Child BP Percentiles and Child and Mother Variables.
Pearson Correlations and Effect Sizes of Child and Maternal Variables with Child BP Percentile
Child Systolic BP Percentile
Child BMI .07
Child WC -.04
Child Cortisol -.10
Child CRP -.06
Mother BMI .31
Mother WC .28
Mother SBP .11
Mother DBP -.02
age children and adolescents with elevations in BPR ranging from 13 to
37% (Nichols, Rice, & Howell, 2011; Sorof & Daniels, 2002), but is higher
than the 17% found in other studies with preschool children (Flynn,
Zhang, Solar-Yohay, & Shi, 2012). Accurate estimates of preschool chil-
dren with elevated BPR are difcult to determine since evidence from
epidemiologic studies suggest that BP may not be routinely measured
in preschool children (Bijlsma, Blufpand, Kaspers, & Bokenkamp,
2014; Shapiro et al., 2012).
The majority of BPR elevations were of SBP, similar to the nding
noted by Flynn et al. (2012) in 3 to 7-year-old children with primary hy-
pertension. This nding also coincides with those studies of school-age
and adolescent participants in which elevations in BPR appear to occur
primarily in SBP (Nichols et al., 2011; Rosner et al., 2013). Elevations
in DBP were not apparent; also noted in previous studies with preschool
children (Flynn et al., 2012; Hansen et al., 2007).
The effect sizes of the relationships between gender and child BP sta-
tus and birth status and child BP status were medium-to-large and me-
dium, respectively. Female and preterm children were more likely to
have elevated BPR. Flynn et al. (2012) also noted elevations in BPR in
3-7 year old children but did not analyze by gender. In addition to gen-
der, those born prematurely were more likely to have elevated BPR. This
is consistent with studies by Bonamy, Klln, & Norman (2012) and
Williams et al. (2004)) who noted elevations in BP in 2.5 year-olds
born extremely preterm and 4 to 7 year-olds born preterm, respectively.
In studies with school-age and adolescent children, elevations in BPR
have been linked to elevated BMI (Maffeis, Banzato, & Talamini, 2008;
Nichols et al., 2011). The effect sizes of the relationships between BMI
and the child SBP and DPB percentiles in this study were negligible.
The majority of children with elevations in BPR (77%) were either nor-
mal weight or underweight, a nding also noted in a study with pre-
school children by Flynn et al. (2012). The two obese participants had
elevated BPRs while the participant who was overweight did not.
While the effect sizes between child BMI and BP percentiles were
negligible, the effect sizes of the relationships between child DBP per-
centiles and cortisol and DBP percentiles and CRP were large and medi-
um, respectively. However, the directions of the relationships were both
negative which is inconsistent with the studies of cortisol and BP (de
Jong, Cranendonk, & van Weissenbruch, 2015; Prodam et al., 2013)and
CRP and BP (Lopez-Jaramillo, Herrera, Garcia, Camacho, & Castillo,
2008; Nappo et al., 2013) and BP in children and adolescents.
While maternal BP was not related to child BP, the effect sizes of the
relationships between maternal BMI, maternal WC and both child SBP
and DBP percentiles were medium and small-to-medium, respectively.
The relationships between maternal BMI and child SBP and DBP have
been noted in other studies with school-age (Bouthoorn et al., 2014)
and preschool children (Oostvogels et al., 2014). However, the relation-
ships between maternal WC and both child SBP and DBP percentiles
have received less attention although WC has been shown to relate to
BP in both children and adults (Pires et al., 2015).
119
Effect Size Child Diastolic Effect Size
.1 = Small BP Percentile .1 = Small
.3 = Medium .3 = Medium
.5 = Large .5 = Large
Negligible .06 Negligible
Negligible .00 None
Small -.62 Large
Negligible -.31 Medium
Medium .27 Small to Medium
Small to Medium .33 Medium
Small .07 Negligible
Negligible .05 Negligible
4. Implications for Research
There were limitations with this pilot study that have implications
for future research. The sample size was small; thus, the observed effect
sizes might be subject to sampling error and may not have been ade-
quate to estimate the inuence of some of the selected factors. The par-
ticipants were all black. Whether the ndings apply to children of other
races and/or ethnicities is not known and should also be examined. Fur-
ther, all of the participants were of low SES, so whether these ndings
apply to children of other SES levels is also unknown. Finally, the
study was conducted in one rural and one urban location in the south-
eastern US. Studies in other locations may yield different results.
Since some of the selected variables, such as child BMI or maternal
BP, did not seem to be associated with child BP and, thus, had very
small or negligible effect sizes, it will be important to examine other
child and maternal variables that may inuence child BP. Among these
could be diet, physical activity, sleep, sodium, and physical environment
in the child and diet, physical activity, educational level and stress in the
mother. Additionally, it will be important to examine those relation-
ships with relevant effect sizes in larger samples in order to test hypoth-
eses. If prevention of hypertension is to be successful, efforts to
determine factors that inuence BP must begin early in childhood.
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