The 2017 American Academy of Pediatrics Clinical Practice Guideline for Screening and Management of High Blood Pressure in Children and Adolescents calls for repeat blood pressure (BP) measurements over a period of weeks to months before confirming the diagnosis of hypertension (10.1542/peds.2017-1904). But what happens to those with elevated BP over longer periods of time, such as a few years? Kaelber et al (10.1542/peds.2019-3778) report their findings about this in a study being released this month in our journal. The authors share with us the results of a 72-month retrospective cohort study in 165 primary care sites. Outcomes were compared among those children with multiple BP measurements during the first 36 months compared to the next 36 months. Despite the large numbers included in this study, only 89,347 had ≥3 BPs taken in the initial 36-month period and only about half had at least 3 BP measurements over the next 36 months.
Of children not lost to follow-up over the entire six years of the study, only about 4% (n=1881) met the criteria for hypertension in the first 36-month period, of whom only 29% (n=542) with the others either having no elevated blood pressures (n=933) or elevated blood pressure but not on at least 3 separate occasions that would qualify as hypertension (n=406).continued to have elevated BP in the next 36-month period.
What do we do about the poor lack of follow-up? Should we feel reassured because most children with elevated BPs self-resolve? Don’t stop worrying just yet—according to an accompanying commentary by Dr. Joseph Flynn, pediatric nephrologist at Seattle Children’s who led the AAP committee that developed the current guidelines for the screening and management of high blood pressure in children (10.1542/peds.2020-018481). Dr. Flynn believes that the take-away message from this study is not that a large number of children have their BPs normalize since the values obtained may be false-negatives given that blood pressure is often not measured correctly. Furthermore, Dr. Flynn notes that 12% of those with elevated BP measurements in the first period progressed to higher stage of hypertension in that second 36-month period. Given the lack of follow-up according to the AAP guidelines, these findings might underestimate the progression of hypertension. Perhaps this paper will put some pressure on all of us to be more adherent to the AAP guidelines for screening for hypertension rather than ignore elevated measurements thinking that most will resolve. Check out this study and commentary which will give you much more to think about then these off-the-cuff thoughts about this study and commentary being shared in this blog.
