A new AAP technical report can help clinicians gain further clarity regarding the methods and approach used to generate the 2017AAPClinical Practice Guideline for Screening and Management of High Blood Pressure in Children and Adolescents.
The report details the systematic review process utilized for identifying and characterizing (e.g., level of evidence) the literature used to generate the 30 key action statements and 27 additional recommendations in the practice guidelines.
The report, Diagnosis, Evaluation, and Management of High Blood Pressure in Children and Adolescents from the Subcommittee on Screening and Management of High Blood Pressure in Children, is available at https://doi.org/10.1542/peds.2018-2096 and will be published in the September issue of Pediatrics.
To generate the 2017 clinical practice guideline (CPG), a broader content outline of 100 topics related to the diagnosis and management of hypertension in youths was condensed into four primary “PICOT” (Patient, Intervention, Comparison, Outcome, Time) questions. Additional topics were searched separately, such as defining hypertension (HTN) in youths, defining left ventricular hypertrophy, the economic impact of HTN screening, patient/child perspectives, evidence gaps and proposed future directions.
Key questions addressed in the technical report and ultimately in the guideline include the following:
PICOT 1: How should systemic HTN (primary HTN, renovascular HTN) be diagnosed in neonates, infants and children (0 to 18 years of age)? How should white coat HTN and masked HTN be diagnosed in children and adolescents? What is the optimal approach for diagnosing HTN in children and adolescents?
PICOT 2: What is the recommended workup for evaluating children and adolescents with suspected or confirmed systemic HTN? How do we best identify the underlying etiologies of secondary HTN in children and adolescents, including renal-, endocrine-, environment-, medication- and obesity-related causes? When should providers suspect a monogenic form of systemic HTN among children and adolescents?
PICOT 3: What is the optimal goal systolic blood pressure and/or diastolic blood pressure for children and adolescents? What nonpharmacologic and pharmacologic therapies are available to treat high blood pressure (HBP) in children and adolescents?
PICOT 4: In children and adolescents 1 to 18 years of age, how do the presence and severity of systemic HTN influence indirect markers of cardiovascular disease and vascular dysfunction (e.g., flow-mediated dilation, carotid intima media thickness), and how does HTN in children impact long-term risk of HTN into adulthood? Among children and adolescents with systemic HTN, how do the presence and the severity of systemic HTN influence comorbidities such as dyslipidemia, obstructive sleep apnea syndrome and cognition?
Compared with prior pediatric HTN guidelines, the 2017 guideline combined clinical expertise with a detailed, systematic review process and an evidence scoring method. Of the nearly 15,000 references identified, 570 were selected for inclusion. Most references were level of evidence C, and the majority of key action statements were of “moderate recommendation.”
Highlights from the technical report include:
- a process flow map detailing the approach used to generate the 2017 guideline;
- a description of the PICOT questions used;
- a detailed description in the appendix of the search terms used to identify key references (including the date and time the search was conducted); and
- strategies for implementing the 2017 guideline blood pressure definitions into the electronic health record.
Overall, the technical report details a comprehensive approach to updating the pediatric hypertension guidelines.
Dr. Baker-Smith, a lead author of the technical report, is a pediatric cardiologist who served as epidemiologist and methodologist for the clinical practice guideline. She is a member of the AAP Subcommittee on Screening and Management of High Blood Pressure in Children.