Pediatrics group issues guidelines
The prevalence of pediatric hypertension has increased since 1988, and yet the condition often goes undiagnosed and untreated, according to a new report published by the American Academy of Pediatrics (AAP).
The report, “Clinical Practice Guidelines for Screening and Management of High Blood Pressure in Children and Adolescents,” includes the Academy’s first set of guidelines for high blood pressure in children. It was published in the September 2017 issue of Pediatrics.
An estimated 3.5 percent of all children and adolescents have hypertension, which is when the blood pressure remains abnormally high. Although the prevalence of hypertension has plateaued in recent years, elevated blood pressure readings often go undetected and untreated, the report says.
The Academy convened a 20-person committee to develop the new evidence-based guidelines on pediatric hypertension, which serve as an update to the most recent set of guidelines, issued in 2004 by the National Heart, Lung, and Blood Institute, which was endorsed by AAP.
The guidelines include new blood pressure tables based on normal-weight children. Previously, such tables included blood pressure measurements in children and adolescents who are overweight or obese – a condition that is likely to increase blood pressure. As a result, the new blood pressure values are lower than those used in prior guidelines and allow for a more precise classification of blood pressure according to body size.
Recommendations rated ‘strong’
The College’s recommendations rated “strong” are:
- Oscillometric devices may be used for BP screening in children and adolescents. When doing so, providers should use a device that has been validated in the pediatric age group. If elevated BP is suspected on the basis of oscillometric readings, confirmatory measurements should be obtained by auscultation.
- Children and adolescents with suspected white-coat hypertension (WCH) should undergo ambulatory blood pressure monitoring (ABPM). Diagnosis is based on the presence of mean systolic blood pressure (SBS) and diastolic blood pressure (DSB) <95th percentile and SBP and DBP load <25%.
- Children and adolescents who have undergone coarctation (narrowing of the artery) repair should undergo ABPM for the detection of hypertension (including masked hypertension, or MH).
- Clinicians should not perform electrocardiography in hypertensive children and adolescents being evaluated for left ventricular hypertrophy.
- Regardless of apparent control of blood pressure with office measures, children and adolescents with chronic kidney disease (CKD) and a history of hypertension (HTN) should have blood pressure assessed by ABPM at least yearly to screen for MH.
- Children and adolescents with CKD and HTN should be evaluated for proteinuria (excessive proteins in the urine).
- Adolescents with elevated BP or HTN (whether they are receiving antihypertensive treatment) should typically have their care transitioned to an appropriate adult care provider by 22 years of age (recognizing that there may be individual cases in which this upper age limit is exceeded, particularly in the case of youth with special healthcare needs). There should be a transfer of information regarding HTN etiology and past manifestations and complications of the patient’s HTN.
- In children and adolescents being evaluated for high BP, the provider should obtain a perinatal history, appropriate nutritional history, physical activity history, psychosocial history, and family history and perform a physical examination to identify findings suggestive of secondary causes of hypertension.
‘Moderate’ recommendations
Recommendations considered “moderate” include the following:
- Blood pressure should be measured annually in children and adolescents =3 years of age.
- BP should be checked in all children and adolescents =3 years of age at every healthcare encounter if they have obesity, are taking medications known to increase BP, have renal disease, a history of aortic arch obstruction or coarctation, or diabetes.
- Trained healthcare professionals in the office should make a diagnosis of hypertension (HTN) if a child or adolescent has auscultatory-confirmed BP readings =95th percentile at three different visits.
- Ambulatory blood pressure monitoring (APBM) should be performed for confirmation of HTN in children and adolescents with office BP measurements in the elevated BP category for one year or more or with stage 1 HTN over three clinic visits.
- Routine performance of ABPM should be strongly considered in children and adolescents with high-risk conditions to assess HTN severity and determine if abnormal circadian BP patterns are present, which may indicate increased risk for target organ damage.
- ABPM should be performed by using a standardized approach with monitors that have been validated in a pediatric population, and studies should be interpreted by using pediatric normative data.
- Home BP monitoring should not be used to diagnose HTN, masked hypertension, or white-coat hypertension, but may be a useful adjunct to office and ambulatory BP measurement after HTN has been diagnosed.
Source: Pediatrics, September 2017, Volume 140/Issue 3, Clinical Practice Guideline for Screening and Management of High Blood Pressure in Children and Adolescents, http://pediatrics.aappublications.org/content/140/3/e20171904