Approximately 3.5% of children and adolescents suffer from hypertension. Left untreated-often the case, since its symptoms are silent-hypertension can lead to organ damage and cardiovascular disease. To improve its detection, management, and treatment, the American Academy of Pediatrics recently updated its pediatric blood pressure (BP) guidelines, previously issued in 2004, with evidence-based recommendations supported by an expert panel review of 15,000 articles published since 2004.

The key change is simplification. A new screening table listing 90th percentile BP values by age and sex for children at the 5th percentile of height makes it easier to identify youngsters requiring additional evaluation. The values have also been recalibrated. Tables establishing cutoff percentiles for pediatric BP levels (normal, elevated, stage 1 and stage 2 hypertension) are now based on normal-weight children. In the earlier guidelines, they were based on population data that included overweight and obese children and adolescents, thereby scaling the values upward since excess weight is known to be a risk factor for hypertension. The new tables, therefore, set BP values several millimeters lower for each cutoff percentile. The practical effect is that more children and adolescents will be correctly identified as having elevated BP.

For teens ages 13 years and older, the simplified BP classifications align with the 2017 American Heart Association and American College of Cardiology adult BP guidelines, facilitating BP management in older adolescents.

Under the new guidelines, normal-weight children three years of age and older need only have BP measured during annual wellness visits. The 2004 guidelines recommended testing at every health encounter, which is still recommended for youngsters with obesity, kidney disease, diabetes, or other underlying conditions that increase their risk of hypertension, or who take medications that raise BP.

Since BP can fluctuate between office visits or even during the same visit (anxiety may produce "white coat hypertension"), youngsters with above-normal BP readings should be retested to confirm their BP levels. If a child's BP remains elevated in three readings over a year's time, further diagnostic evaluation is recommended. The guidelines recommend lifestyle changes for the treatment of children and adolescents with high BP-improved diet, increased physical activity, regular sleep habits-before medication.

The authors recommend additional research to fill gaps in the evidence relating to pediatric hypertension, and urge reassessment and revision of the guidelines about every five years.-Lucy Wang Halpern

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