Screening and Management of High Blood Pressure in Children and Adolescents

Flynn JT, Kaelber DC, Baker-Smith CM, et al., on behalf of the Subcommittee on Screening and Management of High Blood Pressure in Children.
Clinical Practice Guideline for Screening and Management of High Blood Pressure in Children and Adolescents. Pediatrics 2017;Aug 22:[Epub ahead of print].

These pediatric hypertension guidelines are an update to the 2004 “Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents.” The following key points to remember emphasize differences between the new guidelines and the previous document:

  1. The term “elevated blood pressure” has replaced the term “prehypertension.”
  2. There are new normative pediatric blood pressure tables based on normal-weight children. As obese children were excluded in the calculation of normative values, the new thresholds are generally slightly lower than those in the Fourth report.
  3. A new simplified screening table was included, particularly for use in primary care offices, to identify blood pressures needing additional evaluation. The only inputs required for this table are age and sex.
  4. There is simplified blood pressure classification for adolescents ≥13 years of age. This classification aligns with the soon-to-be released American Heart Association/American College of Cardiology adult blood pressure guidelines.
  5. There is a more restrictive recommendation to perform screening blood pressure measurements only at preventative care visits. Exceptions include patients taking medication known to increase blood pressure, obese patients, and those with diabetes, renal disease, or aortic arch obstruction/coarctation, who should have their blood pressure measured at every health care encounter.
  6. The recommendations regarding the initial management of abnormal blood pressure measurements have been streamlined.
  7. The new guidelines include an expanded role for ambulatory blood pressure monitoring (ABPM) in the diagnosis and management of pediatric hypertension. ABPM should be performed for confirmation of hypertension in children with office blood pressure measurements in the elevated blood pressure category for a year or more or with stage I hypertension over three clinic visits.
  8. Children who have undergone coarctation repair should undergo ABPM for the detection of hypertension, including masked hypertension.
  9. The recommendations as to indications for echocardiography in the evaluation of newly diagnosed hypertensive pediatric patients have been updated. It is recommended that echocardiography be performed to assess for cardiac target organ damage at the time of consideration of pharmacologic treatment for hypertension.
  10. The definition of left ventricular hypertrophy has been revised. Left ventricular hypertrophy should be defined as left ventricular mass >51 g/m2.7 for children >8 years of age and defined by left ventricular mass >115 g/body surface area (BSA) for boys and >95 g/BSA for girls.

Keywords: Adolescent, Ambulatory Care, Aortic Coarctation, Blood Pressure, Blood Pressure Determination, Blood Pressure Monitoring, Ambulatory, Child, Diabetes Mellitus, Echocardiography, Hypertension, Hypertrophy, Left Ventricular, Masked Hypertension, Obesity, Pediatric Obesity, Pediatrics, Prehypertension, Primary Health Care, Primary Prevention

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