August 23, 2017

New Guidelines for Diagnosing, Managing Hypertension in Children and Adolescents

CLEVELAND, Ohio -- August 23, 2017 -- The first new national guidelines since 2004 on identifying and treating high blood pressure (BP) in children and adolescents aged 3 to 18 years have been published by the American Academy of Pediatrics (AAP) and appear in the September issue of the journal Pediatrics.

The AAP report, Clinical Practice Guideline for Screening and Management of High Blood Pressure in Children and Adolescents, offers a series of evidence-based recommendations for paediatricians derived from a comprehensive review of nearly 15,000 medical studies published since 2004.

The first-line treatment remains lifestyle changes, as there is a high correlation between hypertension and obesity.

Among the new recommendations is a call to only conduct routine BP measurements at annual preventive care, or “wellness,” visits, as opposed to the 2004 guidelines that urged BP testing anytime a child was in a healthcare setting, such as for emergency room treatment or during a dental visit.

“That volume of testing outside of preventive care or wellness visits produced some false positives,” said David Kaelber, MD, Case Western Reserve University School of Medicine, Cleveland, Ohio. “Sometimes kids are in pain or have other issues that cause their blood pressure to be high in the short-term, but not actually have hypertension, leading to unnecessary worry about elevated blood pressure on the part of parents and the kids themselves. This new guideline should also result in health care savings by reducing unnecessary BP monitoring.”

A second major difference is that the new report removed overweight and obese patients when calculating standards for normal BP in young people -- while retaining the benchmark of labelling high BP as beginning at the 95th percentile and categorised by age, sex, and height.

“Since we know that those who are obese and overweight are more likely to have high blood pressure, removing them from our ‘normal’ calculation pool means that we will pick up more average-weight kids with higher blood pressure than under the old model, potentially preventing serious health problems in later life through earlier diagnosis,” said Dr. Kaelber.

A third difference is a recommendation for diagnosing high BP by using an ambulatory BP monitor that is attached to the body and worn in real-life settings. This replaces the old guideline which resulted in a hypertensive diagnosis after three successive elevated BP readings in a physician's office. In making this recommendation, the report cites significant evidence of “white coat hypertension” linked to fear and anxiety in a clinical setting.

A fourth difference is a recommendation for ordering an echocardiogram for hypertensive young people only if the patient is to be started on medication to treat his or her BP. Under the old guidelines, echocardiograms were routine in cases of abnormal BP whether the patient was on medication or not. Evidence typically shows no health benefits of echocardiograms in young patients whose BP is under control through lifestyle changes in diet and exercise.

For patients aged 13 years and older, the same definitions of abnormal BP apply as adult hypertension guidelines from the American Heart Association and the American College of Cardiology.


SOURCE: Case Western Reserve University

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