Updated guidelines for clinicians managing hypertension in children
Friday, August 25, 2017
Hypertension among adolescents and children is on the rise, and new guidelines are encouraging clinicians to be alert and assertive when noticing signs in young patients. In fact, the guidelines state that an estimated 3.5 percent of all youths in the United States have hypertension — becoming one of the top five chronic diseases for adolescents and children.
The percentage varies by age, race and gender. High blood pressure was shown to be consistently greater in boys than girls, higher among Hispanics and African-American children, and higher among adolescents than younger children.
The increase of hypertension is "probably related to the obesity epidemic that we're seeing in children, but that doesn't completely explain the increase in blood pressure that we're seeing," Dr. Joshua Samuels said to NBC News.
Though obesity can be a factor, researchers said that the underlying cause of high blood pressure can be complicated. Overweight children do not always have hypertension, whereas a child who is considered to be normal weight may have it.
"Untreated, we believe that high blood pressure in a child will lead to high blood pressure when that child becomes an adult, so that would potentially lead to an increased risk of cardiovascular disease later in life," Dr. Joseph T. Flynn said. "The blood pressure levels that are concerning in adults would also be concerning in an older teenager.”
Updated from the 2004 guidelines, the American Academy of Pediatrics' new guidelines were developed to provide updates on topics relevant to diagnosis, evaluation and management of hypertension.
The guidelines state that clinicians often miss — 75 percent of the time — the signs of hypertension. With these news guidelines, more children will be diagnosed more accurately, ultimately allowing the patient to receive the right treatment earlier.
"The revised document recommends the test only for children and adolescents who will be taking medication for abnormal blood pressure, prior to starting the medication," Dr. David Kaelber said to Medscape Medical News. The previous guidelines called for cardiac echocardiogram in all children with hypertension.
As with any medical condition, the appropriate evaluation is critical to any diagnosis. Many clinicians already know, but it's important to remember to get the most detailed data on the patient. This includes patient history, family history, physical examination, laboratory evaluation and imaging.
Once you have all the necessary data, the recommendations suggest doing the following on patient evaluation and management according to BP level:
STAGE 1 HTN:
- If the BP reading is at the stage 1 HTN level and the patient is asymptomatic, provide lifestyle counseling and recheck the BP in 1 to 2 weeks by auscultation;
- If the BP reading is still at the stage 1 level, upper and lower extremity BP should be checked (right arm, left arm, and 1 leg), and BP should be rechecked in 3 months by auscultation. Nutrition and/or weight management referral should be considered as appropriate; and
- If BP continues to be at the stage 1 HTN level after 3 visits, ABPM should be ordered (if available), diagnostic evaluation should be conducted, and treatment should be initiated. Subspecialty referral should be considered.
STAGE 2 HTN:
- 1.If the BP reading is at the stage 2 HTN level, upper and lower extremity BP should be checked (right arm, left arm, and 1 leg), lifestyle recommendations given, and the BP measurement should be repeated within 1 week. Alternatively, the patient could be referred to subspecialty care within 1 week;
- 2.If the BP reading is still at the stage 2 HTN level when repeated, then diagnostic evaluation, including ABPM, should be conducted and treatment should be initiated, or the patient should be referred to subspecialty care within 1 week; and
- 3.If the BP reading is at the stage 2 HTN level and the patient is symptomatic, or the BP is >30 mm Hg above the 95th percentile (or >180/120 mm Hg in an adolescent), refer to an immediate source of care, such as an emergency department (ED).
In total, the authors state that the recommendations include 30 key action statements (updated from 2004) and 27 additional recommendations based on research of about 15,000 published articles from 2004-2016. Because the current AAP recommendations call for the review of guidelines every 5 years, "these 2017 guidelines should be reviewed again in 2022 to see if evidence indicates that they should be updated," Kaelber said.
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