Pediatric hypertension: Often missed and mismanaged

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Applied Evidence

Pediatric hypertension: Often missed and mismanaged

J Fam Pract. 2014 March;63(3):129-136

By

Robert Gauer, MD

Megan Belprez, MD

Caitlyn Rerucha, MD

Delayed recognition of hypertension in children can have lasting consequences. The resources detailed here—including Web-based calculators and at-a-glance tables—can facilitate diagnosis and treatment.

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References

1. McNiece KL, Poffenbarger TS, Tuner JL, et al. Prevalence of hypertension and pre-hypertension among adolescents. J Pediatr. 2007;150:640-644.e1.

2. Moore WE, Eichner JE, Cohn EM, et al. Blood pressure screening of school children in a multiracial school district: the Healthy Kids Project. Am J Hypertens. 2009;22:351-356.

3. Falkner B. What exactly do the trends mean? Circulation. 2007;116:1437-1439.

4. Feber J, Ahmed M. Hypertension in children: new trends and challenges. Clin Sci (Lond). 2010;119:151-161.

5. Hansen ML, Gunn PW, Kaelber DC. Under diagnosis of hypertension in children and adolescents. JAMA. 2007;298:874-879.

6. Boneparth A, Flynn JT. Evaluation and treatment of hypertension in general pediatric practice. Clin Pediatr (Phila). 2009;48:44-49.

7. Ogden CL, Carroll MD, Kit BK, et al. Prevalence of obesity and trends in body mass index among US children and adolescents, 1999-2010. JAMA. 2012;307:483-490.

8. Feld LG, Corey H. Hypertension in childhood. Pediatr Rev. 2007;28:283-298.

9. Rosner B, Cook N, Portman R, et al. Blood pressure differences by ethnic group among United States children and adolescents. Hypertension. 2009;54:502-508.

10. Din-Dzietham R, Liu Y, Bielo MV, et al. High blood pressure trends in children and adolescents in national surveys, 1963 to 2002. Circulation. 2007;116:1488-1496.

11. de Jong F, Monuteaux MC, van Elburg RM, et al. Systematic review and meta-analysis of preterm birth and later systolic blood pressure. Hypertension. 2012;59:226-234.

12. 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.

13. Ramaswamy P, Lytrivi ID, Paul C, et al. Regression of left ventricular hypertrophy in children with antihypertensive therapy. Pediatr Nephrol. 2007;22:141-143.

14. Lande MB, Carson NL, Roy J, et al. Effects of childhood primary hypertension on carotid intima media thickness: a matched controlled study. Hypertension. 2006;48:40-44.

15. Flynn JT. Pediatric hypertension update. Curr Opin Nephrol Hypertens. 2010;19:292-297.

16. Mitchell P, Cheung N, de Haseth K, et al. Blood pressure and retinal arteriolar narrowing in children. Hypertension. 2007;49:1156-1162.

17. Kupferman JC, Lande MB, Adams HR, et al. Primary hypertension and neurocognitive and executive functioning in school-age children. Pediatr Nephrol. 2013;28:401-408.

18. Chen X, Wang Y. Tracking of blood pressure from childhood to adulthood: A systematic review of meta-regression analysis. Circulation. 2008;117:3171-3180.

19. Hypertension. American Academy of Family Physicians Web site. Available at: http://www.aafp.org/patient-care/clinical-recommendations/all/hypertension.html. Accessed February 7, 2014.

20. Screening for high blood pressure: reaffirmation recommendation statement. December 2007. AHRQ publication 08-05105-EF-2. US Preventive Services Task Force Web site. Available at: http://www.uspreventiveservicestaskforce.org/uspstf07/hbp/hbprs.htm. Accessed October 10, 2012.

21. Growth Charts. Centers for Disease Control and Prevention Web site. Available at: http://www.cdc.gov/growthcharts. Accessed July 31, 2012.

22. Podoll A, Grenier M, Croix B, et al. Inaccuracy in pediatric outpatient blood pressure measurement. Pediatrics. 2007;119:e538-e543.

23. Flynn JT, Pierce CB, Miller ER 3rd, et al; Chronic Kidney Disease in Children Study Group. Reliability of resting blood pressure measurement and classification using an oscillometric device in children with chronic kidney disease. J Pediatr. 2012;160:434-440.e.1.

24. Villar VA, Liu T, Jose PA. Recent trends in pediatric hypertension research. J Med Liban. 2010;58:179-184.

25. Swartz SJ, Srivaths PR, Croix B, et al. Cost-effectiveness of ambulatory blood pressure monitoring in the initial evaluation of hypertension in children. Pediatrics. 2008;122:1177-1181.

26. Brady TM, Feld LG. Pediatric approach to hypertension. Semin Nephrol. 2009;29:379-388.

27. Tullus K, Roebuck DJ, McLaren CA, et al. Imaging in the evaluation of renovascular disease. Pediatr Nephrol. 2010;25:1049-1056.

28. Flynn JT. Management of hypertension in the young: role of antihypertensive medications. J Cardiovasc Pharmacol. 2011;58:111-120.

29. ESCAPE Trial Group; Wühl E, Trivelli A, Picca S, et al. Strict blood pressure control and progression of renal failure in children. N Engl J Med. 2009;361:1639-1650.

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PRACTICE RECOMMENDATIONS

› Screen for hypertension in all children over the age of 3 at every visit. C
› Order laboratory evaluation, echocardiography, and renovascular imaging for all children given a diagnosis of hypertension. C
› Advise parents that children with prehypertension and stage 1 hypertension without target-organ damage are eligible to participate in competitive athletics, but those with stage 2 hypertension, target-organ damage, or symptomatic hypertension should not engage in high-static sports (eg, gymnastics, weightlifting, wrestling) until BP is well controlled. C

Strength of recommendation (SOR)

A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series

Childhood hypertension is on the rise: Recent data from the National Health and Nutrition Survey suggest 10% of children and adolescents have prehypertension and 4% have hypertension.^1-4 Unfortunately, the condition often is missed. In a study of 14,187 children and adolescents who had at least 3 well-child visits at an outpatient academic medical center, 507 patients met the criteria for hypertension, yet only 131 (26%) had this diagnosis documented in their electronic health record.⁵

In a survey of 89 pediatricians, >50% of respondents said they were not familiar with the most current published recommendations for diagnosing and treating pediatric hypertension.⁶ Respondents also indicated that the most common reason for not initiating pharmacotherapy for children with hypertension was a lack of familiarity with appropriate antihypertensive agents (54%), followed by concern for adverse medication effects. Delayed diagnosis, evaluation, and treatment of hypertension in young patients can increase the likelihood of serious consequences, including target-organ damage such as left ventricular hypertrophy (LVH). In this review, we’ll describe the factors that put children and adolescents at risk for hypertension, and offer an evidence-based approach to diagnosis and treatment.

Obesity is a key risk factor

An estimated 17% of children aged 2 to 19 are obese.⁷ Obesity increases a child’s risk for hypertension by approximately 3- to 5-fold, and body mass index (BMI) is greater in children with primary hypertension compared with those with secondary hypertension.⁸ Hypertension is more common among Hispanic and non-Hispanic black male children and adolescents compared with their white counterparts; these ethnic disparities are not found in females.^9,10 Poor diets and physical inactivity further contribute to obesity and hypertension risk. Children who were born preterm or had a very low birth weight also are at increased risk.¹¹

Unchecked hypertension can lead to cardiac, vascular damage

Some children and adolescents with undiagnosed and untreated hypertension have evidence of target-organ damage, including cardiac dysfunction and pathologic vascular abnormalities. LVH is present in 20% to 41% of children and adolescents with hypertension.^12,13 Carotid intima-media thickness, an established surrogate marker for atherosclerosis, is abnormally increased in children with hypertension, even after adjusting for BMI.¹⁴ Other target organ effects include impaired cognitive function, reduced glomerular filtration rate, microalbuminuria, and retinal arteriolar narrowing.^15-17

Normal BP standards for children and adolescents are based on gender, age, and height percentile.Pediatric hypertension may persist into adulthood. A meta-analysis of more than 50 studies found that elevated blood pressure (BP) in childhood increases the risk for hypertension as an adult.¹⁸

NHLBI recommendations call for a BP check at every visit

The National Heart, Lung, and Blood Institute (NHLBI) Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents (“the 4th Report”) recommends measuring BP in all children over age 3 during every health care visit.¹² Children under age 3 should have their BP checked in certain circumstances, including preterm delivery, congenital heart disease, recurrent urinary tract infections, renal/urologic disease, organ transplantation, malignancy, and systemic illnesses associated with hypertension.¹² The 4th Report is endorsed by the American Academy of Pediatrics (AAP); however, the American Academy of Family Physicians and the US Preventive Services Task Force have concluded that the evidence is insufficient to recommend for or against routine screening for hypertension in children and adolescents to reduce the risk of cardiovascular disease (CVD).^19,20

Does the child have hypertension? That depends on several factors

Determining whether a child has hypertension requires that you consult national BP standards to determine if he or she is within the normal range. Normal BP standards for children and adolescents are based on gender, age, and height percentile, and provide a precise classification based on body size.¹² These tables are available from the NHLBI Web site at http://www.nhlbi.nih.gov/guidelines/hypertension/child_tbl.htm. Height percentiles in these tables correspond with the Centers for Disease Control and Prevention (CDC) growth charts published in 2000.²¹ The Baylor College of Medicine Children’s Nutrition Research Center has a web-based calculator to help physicians determine BP percentiles in children and adolescents; it is available at http://www.bcm.edu/bodycomplab/Flashapps/BPVAgeChartpage.html. The International Pediatric Hypertension Association also offers BP charts and calculators at http://www.iphapediatrichypertension.org.