The impact of new guidelines on the prevalence of hypertension in children: A cross‐sectional evaluation

Abstract

Updated clinical practice guidelines for screening blood pressures in pediatric patients were published in 2017. They differ from the previous guideline, known as the Fourth Report, providing updated population normal values and blood pressure categorization. We hypothesized that the prevalence of abnormal blood pressure in children and adolescents would be higher using the new clinical practice guidelines. We present a cross‐sectional study of screening blood pressure values for children 3 to 18 years of age obtained during well‐child visits at a primary care clinic. All blood pressure values were categorized using both the Fourth Report and the Clinical Practice Guideline. A total of 2635 blood pressure measurements were extracted, and 2600 were eligible for analysis. Using the clinical practice guideline, the prevalence of hypertension increased to 17.85% compared to 9.5% per the Fourth Report (P < 0.0001). Of those patients classified as having a normal blood pressure by the Fourth Report, 12% changed to abnormal when applying the Clinical Practice Guideline. All subgroups had a significant increase in the prevalence of abnormal blood pressure. The most dramatic increase in the prevalence of stage 1 and stage 2 hypertension was seen in six patient subgroups: males, 3‐12 years of age, Hispanic ethnicity, race designated as other, normal weight, and overweight. Applying the new Clinical Practice Guideline increased the prevalence of elevated blood pressure and stage 1 and stage 2 hypertension in children and adolescents, requiring more follow‐up and intervention than previously expected for this patient population.

Impact of the 2017 American Academy of Pediatrics Guideline on Hypertension Prevalence Compared With the Fourth Report in an International Cohort

“…Those may be due to the static threshold (130/85 mm Hg) of hypertension for adolescents aged ≥13 years in the AAP guideline, which is often lower than using the 95th BP percentile as defined in the Fourth Report, especially for boys. Our findings on downward changes of elevated BP prevalence were similar to 2 previous studies, 29,30 while our findings were different to 2 other studies 31,32 where the authors observed a reclassified upward trend in elevated BP. However, we did find reclassified upward trends in stages 1 and 2 of hypertension, as observed in most previous studies 29,33 but conflicting with the study by Bell et al 31 In the later study, Bell et al 31 found a reclassified upward trend in stage 1 hypertension in children (aged <13 years) but a reclassified downward trend in stage 1 hypertension in adolescents (aged ≥13 years).…”

“…Second, we assessed and confirmed the cardiovascular risk of children with BP values reclassified upward, whereas most previous studies on this topic only showed BP category changes, neglecting the potential cardiovascular risk of reclassified upward children. 29,[31][32][33]37 However, there are some limitations in this study. First, our study was cross-sectional in design, and the potential cardiovascular risk of hypertensive children should be assessed in a prospective cohort study in the future.…”

“…However, in our study, the classification of BP status was based only on 1 occasion, similar to most previous studies on this topic. [32][33][34]37 Third, there were only 2 BP values in the data from Iran and Tunisia, which may have inflated the BP estimates due to the inclusion of the first reading. However, the subgroup analysis by country showed similar trends across each country.…”

A comparison of paediatric hypertension clinical practice guidelines and their ability to predict adult hypertension in an African birth cohort

“…Examining the prevalence of childhood HTN, we found that there was a higher HTN prevalence using the 2017 AAP guideline than using either the 2004 Fourth Report or the 2016 ESH guidelines. Across various childhood and adolescent age points, the 2017 AAP definition indeed showed an expected higher HTN prevalence, which is consistent with the findings from numerous recent cross-sectional studies conducted worldwide [16, 24, 25]. We also found that the prevalence of pre-HTN decreased across our specific ages with a concomitant upward trend in the prevalence of HTN [15; 26].…”

Under‐recognition of pediatric hypertension diagnosis: Examination of 1 year of visits to community health centers

“…12 The change from the 4thR to the 2017 CPG resulted in a higher prevalence of PH and EBP/prehypertension in children, but to our knowledge no study to date reports on improvement in diagnoses rates. 28 The demographic and biometric associations in our study (improved prehypertension diagnosis rates in children who were White, 20 Despite increased prevalence of PH in Black race, our study found lower likelihood of diagnosis in such children. 2,19,28 Studies have shown that physician implicit bias can negatively impact recognition of disease in minorities.…”