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Closing The Blood Pressure Age Gap

New Hypertension Guidelines Developed for Kids and Teens

Closing The Blood Pressure Age Gap

David Kaelber, MD, PhD

When David Kaelber, MD, PhD became co-chair of an American Academy of Pediatrics’ task force to develop new guidelines for screening and managing high blood pressure in children and adolescents, he took on the charge of addressing a medical condition that many people don’t even know exists.

“These new guidelines will give us better tools for identifying and managing what is too often an ‘invisible’ problem,” he said. In a study published in The Journal of the American Medical Association, Kaelber previously found that nearly 75 percent of cases of hypertension and almost 90 percent of cases of pre-hypertension in young people are undiagnosed. When untreated, chronic hypertension can damage the heart, kidneys, and brain

The new report, Clinical Practice Guideline for Screening and Management of High Blood Pressure in Children and Adolescents, represents the first national standards on the topic since 2004. It sets out the extent of the problem and offers a series of evidence-based recommendations for pediatricians based on a comprehensive review of over 570 medical studies published since 2004 (winnowed down from more than 15,000).

Among the public, high blood pressure is commonly associated with stressed adults or those whose lifestyles contribute to elevated BP readings. But about 3.5 percent of all children and adolescents (3-18 years old) in the United States have hypertension – 1.5 million to 2 million young people. “Unfortunately, elevated blood pressure readings in young people regularly go undetected,” said Kaelber, professor of internal medicine, pediatrics, and population and quantitative health sciences at Case Western Reserve University School of Medicine, chief medical informatics officer of the MetroHealth System, and triple alumnus of CWRU.

Kaelber was chosen to co-chair the task force that produced the report because of his extensive experience in the field, including the JAMA study noted above and a subsequent piece in Pediatrics that presented a concise table for identifying elevated blood pressure in young people. The latter article reduced the number of normal and abnormal blood pressure values from 476 to 64, resulting in only one threshold value of elevated BP by gender for each age between three and 18 years. For example, at age 12, blood pressure readings of 115/74 for males and 116/75 for females became thresholds requiring further evaluation. “For the Pediatrics piece, we chose the systolic and diastolic (top and bottom) values from the 90th percentile of previously existing BP standards to be the lowest values in our table,” he said. “This leads to straightforward action: anything above those numbers should prompt further evaluation.”

The new report makes clear, as did its predecessor, that because of the high correlation between hypertension and obesity, the first-line treatment is lifestyle change. Among the dozens of new recommendations is a call for providers to conduct routine blood pressure measurements only during annual preventive care (“wellness”) visits -- not whenever a child is in a health care setting, such as an emergency-room or dental visit, as was the case under the old guidelines. “Universal testing produced a lot of false positives,” said Kaelber. “Sometimes when kids are in pain or have other problems, their blood pressure spikes in the short-term, but they may not actually have hypertension. These false positives led to a lot of unnecessary worrying by both parents and kids. This new guideline will cut down on those fears and should also generate savings by reducing unnecessary BP monitoring.”

A second major difference is a new recommendation for definitively diagnosing high blood pressure in young people. The earlier guideline stipulated a hypertensive diagnosis after three successive elevated blood pressure readings in a physician’s office. The new guideline calls on physicians, after three high-BP office readings, to further track patients’ pressure by having them wear a small digital blood pressure machine in real-life settings, such as walking, eating, exercising, and resting. In making this recommendation, the report cites strong evidence for “white coat hypertension” -- elevated blood pressure readings at the doctor’s office due to anxiety in a clinical setting, but lower ones at home.

A third difference is that the new guidelines were developed in concert with the latest adult standards from the American Heart Association and the American College of Cardiology. As a result, the same definitions of abnormal blood pressure now apply to both children and adults. Previously, the definitions for pediatric and adult hypertension were slightly different, so that on patients’ 18th birthdays, they could go from having a disease to not having a disease.

“The new guidelines are only as good as they change practices,” Kaelber said. “They’re not the end; publishing them is the end of the beginning.”

Now he and his team are raising awareness of the new guidelines at professional meetings and through the media, both professional and lay, as well as developing online training modules that will count for professional re-licensing. “We’re talking to the public through the media because this is not only about educating pediatricians and family practitioners,” he said. “We want parents and grandparents to ask about their children’s blood pressure, in addition to their height and weight, at wellness visits. This invests them in ensuring that their kids’ blood pressure is checked and that interventions are taken if necessary.”

Joseph Flynn, MD, MS, FAAP, chief of the Division of Nephrology at Seattle Children's Hospital, co-chaired the committee that produced the new guidelines.

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