Updated clinical guidelines for childhood hypertension

Updated clinical practice guidelines for childhood hypertension, the first new guidance on this topic in the United States since 2004, have just been published by The American Academy of Pediatrics (AAP).

Joseph Flynn, MD, MS, FAAP, chief, Division of Nephrology, Seattle Children’s Hospital, Seattle, Washington, reviewed the most important changes in the updated clinical practice guidelines in a session titled “What the pediatrician needs to know about the 2017 AAP Guidelines for Childhood Hypertension” at the American Academy of Pediatrics (AAP) National Conference and Exhibition on September 19.

As one of the co-chairs of the AAP committee that wrote the new guideline, Flynn emphasized that a major goal of the updated guideline was to make it easier for clinicians to use while maintaining the focus on providing proper scientific justification for the recommendations.

“We believe that it is important to look for children and adolescents with high blood pressure (BP), and that we hopefully have created something that will help the pediatrician identify those patients and then evaluate them in an appropriate manner,” he said.

Recommended: Improving patient visits

To that end, one of the major changes from the previous guideline published in 2004 are new BP tables that are simplified to make it easier to recognize and identify kids with high BP, according to Flynn.

Other major changes include some modifications in the classification scheme for high BP, as well as an increased reliance on ambulatory BP monitoring (ABPM) to identify high BP in children.

For example, the updated guidelines change the definition of hypertension in children and adolescents, particularly for adolescents aged 13 years and older. In these older children, BP cut points indicative of hypertension are now identical to the cut points used to identify hypertension in adults-systolic BP of >130 mm Hg and/or diastolic BP of ≥80 mm Hg.

In children aged younger than 13 years, hypertension is defined as systolic and/or diastolic BP ≥95th percentile based on the new sex, age, and height tables.

The new guidelines also recommend the use of ABPM to:

·      Confirm the diagnosis of hypertension in children with repeatedly elevated office BP readings.

·      Confirm suspected white coat hypertension.

·      Evaluate masked hypertension in children with a history of repaired coarctation of the aorta.

·      Evaluate BP pattern and risk for hypertensive target organ damage in children with high-risk conditions.

·      Evaluate possible hypertension in children with obstructive sleep apnea.

·      Evaluate BP in heart and kidney transplant recipients.

·      Assess treatment effectiveness in children on antihypertensive medications.

·      Monitor treatment efficacy and possible masked hypertension in children with chronic kidney disease.

Flynn helped clinicians understand how these updated changes will affect the management of children and adolescents with high BP. The need for clinicians to be aware of these changes and to the guidelines in general is underscored by the many children with high BP who are not diagnosed.

“The majority of kids with high BP are not even being recognized,” Flynn said. “This is a problem that is not receiving sufficient attention in the primary care setting.”

NEXT: Commentary

Commentary

Thanks to several seminal, longitudinal research studies, we know now that cardiovascular disease (CVD) begins in youth and tracks into adulthood.^1-4 We also know that there are tools available to decrease CVD risk in childhood and beyond; key to this is early identification and treatment of modifiable CVD risk factors.

Hypertension is one CVD risk factor that has garnered increased attention over the last several decades due to its increased prevalence among children and adolescents and known association with atherosclerosis and left ventricular hypertrophy.⁵ Despite this increased attention, recognition of elevated blood pressure (BP) and hypertension in children remains suboptimal and underdiagnosis remains a problem, despite the advent of electronic record alerts and technology.^6,7

The recent pediatric hypertension guidelines aim to make BP measurement and hypertension screening in children much easier.⁸ It provides clear instructions in text and via a publicly available online instructional video regarding how to properly measure BP via manual auscultation, a necessary step in the clinical diagnosis of hypertension. Whereas electronic health records have made it easier to recognize when a BP is elevated, these systems fail when an updated height is not simultaneously entered or when the BP is not entered into the health record in a timely fashion.

To aid providers in recognizing BP elevations that require more investigation, the new pediatric hypertension guidelines provide a simplified table for all ages. Further, the cut points for elevated BP, stage I hypertension, and stage II hypertension are now standard cut points for all children aged 13 years and older. So, the ease by which adult providers can “eyeball” a BP to determine if it elevated or not has been passed along to pediatric providers for this group of children. This will also facilitate the transition of care for these patients as they transfer to adult providers, as the new cutoffs more closely resemble the adult guidelines.

Probably most notable for children aged younger than 13 years, the new guidelines provide updated normative tables. The tables published in the previous guidelines⁹ included data from over 60,000 healthy children studied in any of 11 research studies conducted over several decades. As a result, 21% of the children contributing BP values to this normative database were overweight or obese.¹⁰ The new tables exclude the data from children with a body mass index ≥85th percentile, resulting in BP norms that are several mm Hg lower than previously published. In addition, the tables now provide the 50th, 90th, 95th, and 95th + 12 mm Hg values instead of 50th, 90th, 95th, and 99th percentiles. This is noteworthy because providers can now use the table to directly determine the BP that corresponds to stage II hypertension (95th + 12 mm Hg) instead of having to calculate it (99th + 5 mm Hg).

Next: Factoring the metabolic X syndrome

Making it easier to identify when a child has an elevated BP is only one of the ways in which this new guideline seeks to improve the cardiovascular health of children. It also provides a more streamlined approach to the diagnosis and evaluation of hypertension.

Clearer guidance is provided regarding the treatment of hypertension, including recommended lifestyle changes and pharmacologic management. Finally, knowledge gaps are identified, to allow for informed interpretation and to guide research efforts.

-Tammy M. Brady, MD, PhD, associate professor of Pediatrics, medical director, Pediatric Hypertension Program, Division of Pediatric Nephrology, Johns Hopkins University, Baltimore, Maryland.

REFERENCES

1. Berenson GS, Srinivasan SR, Bao WP 3rd, Tracy RE, Wattigney WA. Association between multiple cardiovascular risk factors and atherosclerosis in children and young adults. The Bogalusa Heart Study. N Engl J Med. 1998;338(23):1650-1656.

2. Strong JP, Malcom GT, McMahan CA, et al. Prevalence and extent of atherosclerosis in adolescents and young adults: implications for prevention from the Pathobiological Determinants of Atherosclerosis in Youth Study. JAMA. 1999;281(8):727-735.

3. Lauer RM, Clarke WR. Childhood risk factors for high adult blood pressure: the Muscatine Study. Pediatrics. 1989;84(4):633-641.

4. Shear CL, Burke GL, Freedman DS, Berenson GS. Value of childhood blood pressure measurements and family history in predicting future blood pressure status: results from 8 years of follow-up in the Bogalusa Heart Study. Pediatrics. 1986;77(6):862-869.

5. Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents; National Heart, Lung, and Blood Institute. Expert panel on integrated guidelines for cardiovascular health and risk reduction in children and adolescents: summary report. Pediatrics. 2011;128(suppl 5):S213-S256.

6. Brady TM, Neu AM, Miller ER 3rd, Appel LJ, Siberry GK, Solomon BS. Real-time electronic medical record alerts increase high blood pressure recognition in children. Clin Pediatr (Phila). 2015;54(7):667-675.

7. Rinke ML, Singh H, Heo M, et al. Diagnostic errors in primary care pediatrics: Project RedDE. Acad Pediatr. August 10, 2017. Epub ahead of print.

8. Flynn JT, Kaelber DC, Baker-Smith CM, et al; Subcommittee on Screening and Management of High Blood Pressure in Children. Clinical Practice Guideline for Screening and Management of High Blood Pressure in Children and Adolescents. Pediatrics. 2017;140(3):e20171904.

9. National High Blood Pressure Education Program Working Group on High Blood Pressure in Children and Adolescents. The fourth report on the diagnosis, evaluation, and treatment of high blood pressure in children and adolescents. Pediatrics. 2004;114(2 suppl 4th report):555-576.

10. Rosner B, Cook N, Portman R, Daniels S, Falkner B. Determination of blood pressure percentiles in normal-weight children: some methodological issues. Am J Epidemiol. 2008;167(6):653-666.