“The U.S. clinical community falls way short” of adequately following blood pressure levels in children and adolescents, agreed Julia Steinberger, MD, professor and director of pediatric cardiology at the University of Minnesota in Minneapolis. She chalks this up to several factors: time-pressured clinicians who may let blood pressure slide when other aspects of a visit require more attention and the index of suspicion for elevated blood pressure is low, insufficient education to the primary-care community on how to proceed once an elevated blood pressure reading is made, the difficulty of measuring blood pressure in young or uncooperative patients, and lack of size-appropriate equipment.
Dr. Julia Steinberger
Once a single high pressure is recorded, ideal follow-up means measuring and finding elevated blood pressures again on at least two subsequent visits, followed by even more confirmation with home monitoring or 24-hour ambulatory blood pressure monitoring (ABPM), now considered the gold standard for both diagnosing and following pediatric patients with hypertension, especially if they receive antihypertensive medications. In 2014, a scientific statement from the American Heart Association said routine APBM was indicated to confirm the diagnosis of hypertension in a patient with high casual blood pressure measurements. Not many primary-care physicians have ready access to or experience using and interpreting ABPM.
Other reasons for low diagnostic rates include therapeutic inertia, and the sheer complexity and time of identifying what is a high blood pressure reading, at least until automated calculation of high levels by EMRs became possible. “With a paper analysis you need to look at two different charts” and factor in the patient’s sex, age, and height to determine if a pressure reading is high or not for a particular patient. “Diagnosis has been a problem, especially in busy practice,” noted Dr. Brady. “I think we are addressing that with the EMR and pop-up alerts.”
Streamlining the diagnostic process
“We have a complex way to diagnose hypertension in kids,” admitted Bonita Falkner, MD, who chaired the Fourth Report panel that produced the complicated diagnostic process still used today. “It’s complex and tedious to calculate. There have been a number of reports of missed hypertension because of the complexity of the tables,” said Dr. Falkner, professor and director of hypertension and obesity research at Thomas Jefferson University in Philadelphia. “Because it’s so burdensome to diagnose the detection rate of hypertension is not as accurate as it should be. Hopefully this will be improved with the new guidelines. We plan to make them simpler, easier to use and more streamlined,” she said in an interview.
“One of the challenges is how to make high blood pressure identification simpler and more straightforward. Without question there are children and adolescents with persistently high blood pressures who fall through the cracks,” said Stephen R. Daniels, MD, professor and chairman of pediatrics at the University of Colorado in Aurora. “Recognizing hypertension in adults is much simpler, with a single set of values. The AAP is in the process of developing new guidelines and one goal is to make blood pressure measurement and recognition of hypertension as simple as possible. There is a tension between simplicity and precision. Finding the right balance will be the trick.”
Dr. Falkner highlighted two other new aspects the revised pediatric hypertension recommendations will address. The panel appears to be on track to recalculate the reference blood pressure tables to eliminate the contribution of overweight and obese children and adolescents. Because high blood pressure is defined statistically--pressures at or above the 95th percentile for a child’s sex, age and height--inclusion of overweight and obese children and adolescents in the databases that produced the original tables skewed the 95th percentile thresholds higher than they would be for those who are at normal-weights. “It will make the reference numbers somewhat lower, but not dramatically lower,” Dr. Falkner said.
When the 2004 Fourth Report was written and the calculation tables created “it was early in the obesity epidemic and we were not as tuned into it as a problem” for hypertension,” said Dr. Daniels, also a member of the Fourth Report panel.
Another new aspect will likely be highlighting the role of overweight in addition to obesity as a hypertension risk factor. “In 2004, obesity was a concern but overweight was considered just a risk factor for obesity. Now if a child is overweight we know they are also at increased risk for having high blood pressure,” said Dr. Falkner. “We’ve been trying to get an update of the Fourth Report going for some time; a lot has happened since 2004.”