Hypertension is frequently undiagnosed in children. Several methods have been developed to simplify screening for elevated blood pressure (BP) in children.
to assess the performance of different screening tools in identifying elevated BP in the pediatric population.
Data sources such as PubMed, Embase, Web of Science, Cochrane, and Scopus were searched up to March 2016.
Studies providing measures of diagnostic performance of screening tools and that used age-, sex-, and height-specific BP percentile as the reference standard were included.
Data regarding the population, screening tools used to define elevated BP, and diagnostic criteria of BP were extracted. Available data on true-positive, false-positive, true-negative, and false-negative results were also extracted to construct a 2 × 2 contingency table.
A total of 16 eligible studies that evaluated 366 321 children aged 3 to 18 years were included in the meta-analysis. Nine screening tools were included in this study, in which the BP-to-height ratio, the modified BP-to-height ratio, and tables based on age categories had the highest sensitivities (97–98%) but moderate specificities (71–89%).
Limitations included that BP measurements in most studies were based on 1 visit only and there was heterogeneity between the studies.
Several user-friendly screening tools could improve the screening of elevated BP in the pediatric population.
Comments
RE: “Re:Performance of user-friendly screening tools for elevated blood pressure in children”
We appreciate the attention given by Bo Xi and coworkers to our recently published paper (“Performance of User-Friendly Screening Tools for Elevated Blood Pressure in Children”) in this journal1. They recommended using the height-specific tables developed by Chiolero et al2. However, we think some aspects of this opinion deserve further comments. First, the sensitivities were not very well, 90% in boys and 89% in girls3. In our meta analysis the sensitivity was only 83%1. It means that over one-tenth to two-tenth of children were undiagnosed. As the screening methods, high sensitivity is important. Although the sensitivity of the Chiolero table may be improved after three repeated blood pressure(BP) measurements. Because children with missed diagnosis had slightly elevated BP (BP level relatively close to the 95th percentile), they might not have truly sustained elevated BP. But this opinion has not been proven so far. Second, the positive predictive value elevated with the rising of cut-off points. In the study of Bo et al3, the positive predictive value elevated with the rising of cut-off points. The cut-off points of BP elevated with the rising of height percentiles. In Mitchell table and Kaelber table, the positive predictive values of 95th height percentiles were higher than the positive predictive values of 5th and 50th height percentiles.
The following is the response to other comments. First, Mitchell table and Kaelber table is based on the 90th percentile of BP values from the 2004 Fourth Report. It has been mentioned in our study. We do this just to show that the performance of Mitchell table and Kaelber table for identifying prehypertension and hypertension. Second, the BP values from the 2004 Fourth Report was accepted by the European Society of Hypertension4. It should be mentioned in the article. This is our negligence. Third, Meta-Disc 1.4 statistical software cannot calculate the positive and negative predictive values.
References
1. Ma C, Wang R, Liu Y, et al. Performance of User-Friendly Screening Tools for Elevated Blood Pressure in Children. Pediatrics. 2017 Jan 5. doi: 10.1542/peds.2016-1986.
2. Chiolero A, Paradis G, Simonetti GD, Bovet P. Absolute height-specific thresholds to identify elevated blood pressure in children. J Hypertens. 2013;31(6):1170–1174.
3. Ma C, Kelishadi R, Hong YM,et al. Performance of Eleven Simplified Methods for the Identification of Elevated Blood Pressure in Children and Adolescents. Hypertension. 2016;68(3):614-620.
4. Lurbe E, Cifkova R, Cruickshank JK, et al; European Society of Hypertension. Management of high blood pressure in children and adolescents: recommendations of the European Society of Hypertension. J Hypertens. 2009;27(9):1719–1742.
Re: Performance of User-Friendly Screening Tools for Elevated Blood Pressure in Children
We read with interest the systematic review and meta-analysis by Ma et al.1 assessing the performance of several user-friendly screening tools for elevated blood pressure (BP) in children. While the review provides useful information, we have however several concerns.
First, the simplified table developed by Mitchell et al. (original reference 12), which uses age only to screen for elevated BP, is based on the 90th percentile of BP values from the 2004 Fourth Report. We believe that it is inadequate to use this table to define hypertension (i.e. BP ≥95th percentile) in the three studies included in the review (original references 12, 28, 29). Similarly, the simplified table using sex and age developed by Kaelber et al. (original reference 13) is also based on the 90th percentile of BP values from the 2004 Fourth Report, and it is also unsuitable to use this table to define hypertension (i.e. BP ≥95th percentile) in the four studies in the review (original references 26-29).
Second, the European guidelines of the European Society of Hypertension for the diagnosis and management of high BP in children and adolescents 4 recommend the use of BP values from the 2004 Fourth Report. Thus, the use of the term “European criterion” in the review (e.g. supplemental table 5) is misleading.
Third, the review assessed the performance of several simplified methods based on sensitivity and specificity and related statistics (likelihood ratio and area under the curve) (Tables 2-3 of the review). It would be important to also consider positive and negative predictive values of the tests, which provide information on efficiency of the tests in actual populations. Indeed, high sensitivity and specificity do not necessarily indicate high performance. This is particularly true for conditions with low prevalence, such as hypertension in children.
Fourth, the authors recommend using the two simplified tables by Mitchell et al. and Kaelber et al. However their review did not consider our recent review on the same topic.5 Based on 58,899 children and adolescents from 7 countries, we found low positive predictive values for both the table of Mitchell et al (0.32 in boys and 0.41 in girls) and the table of Kaelber et al (0.40 in boys and 0.54 girls). While we found that most simplified methods had fairly similar high sensitivity and specificity (generally >0.80), we recommended using the height-specific tables developed by Chiolero et al 4 for two reasons. First, this table is particularly user-friendly and includes only 11 height values. Second, most importantly, both the positive predictive value and the negative predictive value were markedly higher for Chiolero’s table (all values above 0.84) than for either the Mitchel and Kaelber methods (values ranging between 0.32 and 0.54).
References
1. Ma C, Wang R, Liu Y, et al. Performance of User-Friendly Screening Tools for Elevated Blood Pressure in Children. Pediatrics. 2017 Jan 5. doi: 10.1542/peds.2016-1986.
2. Lurbe E, Cifkova R, Cruickshank JK, et al; European Society of Hypertension. Management of high blood pressure in children and adolescents: recommendations of the European Society of Hypertension. J Hypertens. 2009;27(9):1719–1742.
3. Ma C, Kelishadi R, Hong YM,et al. Performance of Eleven Simplified Methods for the Identification of Elevated Blood Pressure in Children and Adolescents. Hypertension. 2016;68(3):614-620.
4. Chiolero A, Paradis G, Simonetti GD, Bovet P. Absolute height-specific thresholds to identify elevated blood pressure in children. J Hypertens. 2013;31(6):1170–1174
Re: Performance of User-Friendly Screening Tools for Elevated Blood Pressure in Children
We read with interest the systematic review and meta-analysis by Ma et al.1 assessing the performance of several user-friendly screening tools for elevated blood pressure (BP) in children. While the review provides useful information, we have however several concerns.
First, the simplified formula of Somu et al.2 for screening pediatric hypertension was developed based on the 1996 Updated Task Force Report on high BP in children and adolescents.3The authors use the simplified formula in the three studies included in their review (original references 27-29) but they infer their results to the 2004 US Fourth Report 4. As the cut-offs for elevated BP differ between the 1996 Updated Task Force Report and the 2004 Fourth Report, an updated formula should first be developed based on the 2004 Fourth Report.
Second, the simplified table developed by Mitchell et al.5, which uses age only to screen for elevated BP, is based on the 90th percentile of BP values from the 2004 Fourth Report. We believe that it is inadequate to use this table to define hypertension (i.e. BP ≥95th percentile) in the three studies included in the review (original references 12, 28, 29). Similarly, the simplified table using sex and age developed by Kaelber et al. 6 is also based on the 90th percentile of BP values from the 2004 Fourth Report, and it is also unsuitable to use this table to define hypertension (i.e. BP ≥95th percentile) in the four studies in the review (original references 26-29).
Third, the European guidelines of the European Society of Hypertension for the diagnosis and management of high BP in children and adolescents 7 recommend the use of BP values from the 2004 Fourth Report. Thus, the use of the term “European criterion” in the review (e.g. supplemental table 5) is misleading.
Fourth, the review assessed the performance of several simplified methods based on sensitivity and specificity and related statistics (likelihood ratio and area under the curve) (Tables 2-3 of the review). It would be important to also consider positive and negative predictive values of the tests, which provide information on efficiency of the tests in actual populations. Indeed, high sensitivity and specificity do not necessarily indicate high performance. This is particularly true for conditions with low prevalence, such as hypertension in children.
Fifth, the authors recommend using the two simplified tables by Mitchell et al. and Kaelber et al. However their review did not consider our recent review on the same topic.8 Based on 58,899 children and adolescents from 7 countries, we found low positive predictive values for both the table of Mitchell et al (0.32 in boys and 0.41 in girls) and the table of Kaelber et al (0.40 in boys and 0.54 girls). While we found that most simplified methods had fairly similar high sensitivity and specificity (generally >0.80), we recommended using the height-specific tables developed by Chiolero et al 9 for two reasons. First, this table is particularly user-friendly and includes only 11 height values. Second, most importantly, both the positive predictive value and the negative predictive value were markedly higher for Chiolero’s table (all values above 0.84) than for either the Mitchel and Kaelber methods (values ranging between 0.32 and 0.54).
References
1. Ma C, Wang R, Liu Y, et al. Performance of User-Friendly Screening Tools for Elevated Blood Pressure in Children. Pediatrics. 2017 Jan 5. doi: 10.1542/peds.2016-1986.
2. Somu S, Sundaram B, Kamalanathan AN. Early detection of hypertension in general practice. Arch Dis Child. 2003;88(4):302.
3. National High Blood Pressure Education Program Working Group. Update on the Task Force (1987) on high blood pressure in children and adolescents. Pediatrics 1996;98 (4 Pt 1)::649–658.
4. National High Blood Pressure Education Program Working Group on High Blood Pressure in Children and Adolescents. The fourth report on the diagnosis, evaluation, and treatment of high blood pressure in children and adolescents. Pediatrics. 2004;114 (2 suppl 4th Report):555–576.
5. Mitchell CK, Theriot JA, Sayat JG, Muchant DG, Franco SM. A simplifi ed table improves the recognition of paediatric hypertension. J Paediatr Child Health. 2011;47(1–2):22–26.
6. Kaelber DC, Pickett F. Simple table to identify children and adolescents needing further evaluation of blood pressure. Pediatrics. 2009;123(6): e972-974.
7. Lurbe E, Cifkova R, Cruickshank JK, et al; European Society of Hypertension. Management of high blood pressure in children and adolescents: recommendations of the European Society of Hypertension. J Hypertens. 2009;27(9):1719–1742.
8. Ma C, Kelishadi R, Hong YM,et al. Performance of Eleven Simplified Methods for the Identification of Elevated Blood Pressure in Children and Adolescents. Hypertension. 2016;68(3):614-620.
9. Chiolero A, Paradis G, Simonetti GD, Bovet P. Absolute height-specific thresholds to identify elevated blood pressure in children. J Hypertens. 2013;31(6):1170–1174.