New blood pressure tables and streamlined recommendations are among the changes in new pediatric hypertension guidelines that can help pediatricians identify and address this generally asymptomatic and often-unrecognized chronic disease.
The evidence-based clinical practice guideline (CPG) focuses on the diagnosis, evaluation and initial management of abnormal blood pressures in the ambulatory setting. Clinical Practice Guideline for Screening and Management of High Blood Pressure in Children and Adolescents, from the AAP CPG Subcommittee on Screening and Management of High Blood Pressure in Children, is available at http://pediatrics.aappublications.org/content/early/2017/08/21/peds.2017-1904 and is published in the September issue of Pediatrics. The guideline updates the 2004 The Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents from the National Heart, Lung, and Blood Institute (NHLBI).
Pediatric hypertension, occurring in 2%–5% of all pediatric patients, is one of the top five chronic diseases in children and adolescents. The diagnosis is missed in up to 75% of pediatric patients in primary care settings, and appropriate medication initiation occurs much less frequently than is indicated, according to current guidelines.
Beginning in 2014, the multidisciplinary subcommittee, which included a parent representative, reviewed approximately 15,000 articles published since the prior guideline was issued.
Highlights of the new pediatric hypertension guideline include:
- development based on a strict evidence-based approach as recommended by the National Academy of Medicine and the NHLBI;
- replacement of the term “prehypertension” with “elevated blood pressure”;
- new normative blood pressure tables based on children with normal weight;
- simplified screening table for identifying blood pressures needing further evaluation;
- simplified blood pressure classification in adolescents 13 years of age and older that aligns with forthcoming American Heart Association/American College of Cardiology adult blood pressure guidelines;
- a more limited recommendation to perform screening blood pressure measurement only at preventive care visits;
- streamlined recommendations on initial evaluation and management of abnormal blood pressures;
- expanded role for ambulatory blood pressure monitoring in both diagnosis and ongoing management of pediatric hypertension;
- more limited recommendation on when to perform an echocardiogram in the evaluation of newly diagnosed hypertensive pediatric patients (generally only before medication initiation);
- revised definition of left ventricular hypertrophy;
- revised treatment goals based on published evidence; and
- 30 evidence-based key action statements and an additional 27 clinical recommendations based on expert opinion.
Dr. Flynn and Dr. Kaelber are among the co-authors of the clinical practice guideline and served as co-chairs of the subcommittee.