Childhood prevention of essential hypertension

Differences in SBP, BMI, and Stress with AUDIT Score in Adolescents

Background:

Consumption of alcohol by adolescents is known to have negative effects on their psychological health (ie.g., depression and stress) and physical health.

Objective:

To investigate factors influencing systolic blood pressure, body mass index, and stress according to Alcohol Use Disorders Identification Test scores among adolescents.

Methods:

This descriptive study included 535 adolescents younger than 20 years who participated in the Sixth National Health and Nutrition Survey conducted in middle and high schools in 2013. Data collected were analyzed using PASW Statistics version 23.0.

Results:

Mean age of these subjects was 15.20 ± 0.08 years. There were 268 (51.0%) male students and 286 (48.6%) middle-school students. Their systolic blood pressure, body mass index, and stress scores were 108.79 ± 0.54 mmHg, 21.22 ± 0.19 kg/m2, and 2.06 ± 0.04, respectively. In low-risk group (Alcohol Use Disorders Identification Test scores ≤ 7), sex (male) and body mass index explained 22.9% of the variance in systolic blood pressure model (Wald F = 35.28, p < 0.001). Systolic blood pressure was the only significant factor influencing body mass index, with an explanatory power of 16.4% (Wald F = 13.91, p < 0.001). Depression was a significant influencing variable for the stress model, with an explanatory power of 15.1% (Wald F = 16.20, p < 0.001). Stress was the only significant factor influencing the body mass index model in the high-risk group (Alcohol Use Disorders Identification Test scores > 7), with the explanatory power of 14.3% (Wald F = 4.14, p = 0.018).

Conclusion:

This study found that systolic blood pressure was an influencing factor of body mass index model in both groups while depression was the main factor influencing stress in low-risk group adolescents.

Clinical Practice Guideline for Screening and Management of High Blood Pressure in Children and Adolescents

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." Significant changes in these guidelines include (1) the replacement of the term "prehypertension" with the term "elevated blood pressure," (2) new normative pediatric blood pressure (BP) tables based on normal-weight children, (3) a simplified screening table for identifying BPs needing further evaluation, (4) a simplified BP classification in adolescents ≥13 years of age that aligns with the forthcoming American Heart Association and American College of Cardiology adult BP guidelines, (5) a more limited recommendation to perform screening BP measurements only at preventive care visits, (6) streamlined recommendations on the initial evaluation and management of abnormal BPs, (7) an expanded role for ambulatory BP monitoring in the diagnosis and management of pediatric hypertension, and (8) revised recommendations on when to perform echocardiography in the evaluation of newly diagnosed hypertensive pediatric patients (generally only before medication initiation), along with a revised definition of left ventricular hypertrophy. These guidelines include 30 Key Action Statements and 27 additional recommendations derived from a comprehensive review of almost 15 000 published articles between January 2004 and July 2016. Each Key Action Statement includes level of evidence, benefit-harm relationship, and strength of recommendation. This clinical practice guideline, endorsed by the American Heart Association, is intended to foster a patient- and family-centered approach to care, reduce unnecessary and costly medical interventions, improve patient diagnoses and outcomes, support implementation, and provide direction for future research.

The relationship between blood pressure, anthropometric indices and metabolic profile in adolescents: a cross sectional study

OBJECTIVE

To investigate the relationship between blood pressure, anthropometric indices and metabolic profile in adolescents.

METHODS

The present cross sectional study was conducted in 1005, 12-y-old junior students referred to 15 urban health centers of Rasht. Samples were recruited randomly and data were collected in a form which consisted of demographic characteristics, history of disease in samples and their immediate families, birth weight, physical examination and clinical examination including height, weight, blood pressure and body mass index. Also, metabolic profiles including fasting blood sugar (FBS), blood sugar (BS), cholesterol, and triglyceride (TG), low density lipoprotein (LDL), high-density lipoprotein (HDL) and insulin levels were measured. Data were analyzed in SPSS software, by descriptive and analytic statistics and p value 0.05 was considered statistically significant.

RESULTS

Eight hundred fifty nine adolescents consisting of 550 (64 %) boys and 309 (34 %) girls participated in this study; 11.4 % (84/739 cases) of the participants had hypertension. The strongest correlation was seen between systolic blood pressure and weight, waist or hip circumferences and insulin levels. Also, FBS had very weak correlation with blood pressure.

CONCLUSIONS

Thus, weight, waist and hip circumferences, insulin levels, high TG and low HDL have been indicated as the strongest correlating factors for high blood pressure.Thus, these factors should be investigated in high risk children and followed in hypertensive child to monitor cardiometabolic risk factors.

Blood pressure measurements on children in the emergency department

BACKGROUND

There is no consensus on routine blood pressure (BP) measurement for children presenting to the ED. By contrast, BP measurements are performed routinely in adult ED. With increasing childhood obesity, and the knowledge that elevated BP in childhood correlates with hypertension in adulthood, routine BP measurement in children should be considered.

OBJECTIVE

To review the current practice of BP measurement in children presenting to the ED of Princess Margaret Hospital for Children, Perth, Western Australia, a tertiary referral paediatric centre.

METHOD

A prospective observational study of 504 children presenting to the ED over a 6 month period in 2003.

RESULTS

In total, 114 children (22.6%) had their BP measured. A total of 35 (30.7%) had a BP above the 95th percentile for age and sex. In total, 19 (54.3%) of 35 with abnormal BP had their BP remeasured. Only one child of 10 with consecutive hypertensive measurements was followed up. BP measurement was more common in children aged 2 years and above, and in higher triage category patients.

CONCLUSIONS

The present study demonstrates that BP measurement in the ED is both relatively infrequent and inconsistent. Further research into this area is required to determine the usefulness and feasibility of routine BP measurements in children presenting to the ED. This might improve the quality of health care and positively impact on public health for the future.

A diagnostic approach for the child with hypertension

Hypertension during childhood is not rare, with an estimated prevalence of between 1% and 2%, although it is often an underrecognized clinical entity. Elevated blood pressure may be a sign of underlying disease or it may represent early onset of essential hypertension. In recent years the measurement of blood pressure has been emphasized as an important component of the routine pediatric physical examination that enables early detection of children with hypertension. In the evaluation of the child with documented blood pressure elevation, confirmation of truly and persistently elevated blood pressure is of the utmost importance. In addition, a thorough history and a full clinical examination are essential. These are followed by appropriate investigations, which are tailored to the age of the child and to the severity of the blood pressure elevation. Investigations should not only focus on a search for the underlying cause, but also on establishing effects on target organs, complications or additional diseases and on assessment of the total cardiovascular risk to the individual patient. An algorithm, which is a valuable diagnostic tool for the diagnosis and management of the child with hypertension, is presented. All children with confirmed hypertension need long-term follow-up, counseling and treatment. In those cases where an underlying cause of the hypertension is detected, the established diagnosis then determines the specific therapy and management.

Integrated perinatal health framework. A multiple determinants model with a life span approach

BACKGROUND

Despite great strides in improving prenatal care utilization among American women, key perinatal indicators have remained stagnant or worsened in the past decade, and the United States continues to rank near the bottom compared to other developed countries. A new approach is needed if we are to achieve improvements in perinatal health.

METHODS

To propose a new framework that integrates a "life span" approach with a multiple determinants model.

RESULTS

We recognize that (1) powerful influences on outcome occur long before pregnancy begins; (2) pregnancy outcome is shaped by social, psychological, behavioral, environmental, and biological forces; and (3) the demography of pregnancy has changed dramatically in the last few decades with more women delaying their first birth. Approaches that simultaneously consider the entire life span as well as multiple determinants may need to be adopted. We propose a framework that integrates these approaches and is supported by the research literature. The life span perspective focuses attention toward the preconceptional and interconceptional periods as targets for intervention in improving perinatal health. The multiple determinants model distinguishes among concepts of disease, health and functioning, and well-being for both women and their offspring.

CONCLUSIONS

Our intent is to influence how policymakers, public health professionals, clinicians, and researchers approach perinatal health.

Casual blood pressure and ambulatory blood pressure measurement in children

Some epidemiological studies on blood pressure among children and adolescents have revealed that blood pressure levels in childhood are the strongest predictors of adult blood pressure levels. In the adult population, hypertension causes a two to threefold increase in an individual's risk of cardiovascular morbidity. Cardiovascular risk depends on blood pressure itself, coexistent risk factors and whether there is hypertensive end-organ damage. Therefore, accuracy in determining blood pressure is essential and a standardized protocol should be considered for blood pressure measurement, which would make the comparison of results obtained by different studies in different countries possible. This article reviews the main determinants of accuracy for casual and ambulatory blood pressure measurements in children.

The frequency of blood pressure measurements in children in four EDs

The study's objective was to assess the frequency of triage blood pressure measurements in pediatric patients and the recognition of an elevated blood pressure. The design was retrospective and included chart review. The setting consisted of four emergency departments associated with one medical school, including one level I academic center, two level II Community departments, and a regional children's hospital. A convenience sample of 437 patients, aged 1 month to 18 years, was selected. The frequency of triage blood pressure measurements was recorded. The number of patients whose blood pressure was higher than the 90th percentile for age and sex as established by the Second Task Force on Blood Pressure Control in Children was also recorded. The frequency of a second blood pressure measurement in patients with an elevated initial blood pressure was recorded. All frequency data were stratified by hospital and by age group. The results showed 294/437 (66%) of children had blood pressures measured at triage. Of these measurements, 153/294 (52%) reflected blood pressures greater than the 90th percentile for age and sex, but only 58/153 (38%) of patients with such blood pressures had a second blood pressure measured. Hospitals varied in their frequency of blood pressure measurement. Adolescents had their blood pressure measured more frequently, 981105 (93%) than two to 12-year-olds, 144/185 (78%) or 1-month to 2-year-olds, 52/147 (35%). Frequency of triage blood pressure measurements in children varied by institution and increased in frequency with age.

Combining annual blood pressure measurements in childhood to improve prediction of young adult blood pressure

Tracking correlations of blood pressure (BP) have been reported between levels measured in a single year during both childhood and adulthood. Because of the variability of BP, these correlations increase with the number of visits and measurements per visit in each year. It remains unclear, however, whether such correlations would improve further by combining BP data collected over several years. From 1978-1981, BP was measured annually in a cohort of 339 children in East Boston, MA, at four visits one week apart with three measurements per visit. Of this cohort, then aged 18-26 years, 316 were re-examined in 1989-1990 at three visits one week apart with three measures per visit. Tracking correlations were estimated from levels measured in a single year as well as means averaged over several years in childhood, adjusting for age, year of measurement, as well as smoking, alcohol and oral contraceptive use. Multivariate models were fit to estimate tracking correlations from childhood to young adulthood adjusting for within-person variability. Using a single year in childhood, these were 0.49 in boys and 0.59 in girls for systolic BP and 0.39 and 0.48 for diastolic BP (all p<0.001). Using the long-term average in childhood and adjusting for variability across years, these values were 0.55 in boys and 0.66 in girls for systolic BP and 0.47 and 0.57 for diastolic BP (all p<0.001). We observed concomitant increases in the predictive value of childhood BP for young adult BP. These results suggest that averaging BP over at least two years during childhood increases tracking correlations and improves the prediction of adult values from childhood levels.

Effect of socioeconomic status on the blood pressure in children living in a developing country

BACKGROUND

Lower socioeconomic status has been reported to favor higher blood pressure both during childhood and adulthood, because obesity is more prevalent among this population. The aim of the present study was to evaluate the effect of socioeconomic status on blood pressure and prevalence of obesity among children living in a developing country.

METHODS

Prepubertal primary school children (total number 1024, male/female ratio 513/511, mean age 10.32 +/- 0.60 years) living in Izmir, a metropolis of Turkey, were enrolled in the present study. The children were classified into three groups according to the locations of their schools as those from the well-developed (WD; n = 290), moderately developed (MD, n = 356) and underdeveloped (UD, n = 378) areas. Body mass index (BMI), ratio of BMI to the 50th percentile value of BMI for that age (BMI%) and systolic (SBP) and diastolic blood pressures (DBP) were determined in all children. Each socioeconomic group was subdivided into three subgroups with respect to BMI% as those with less than 90% (SG(< 90)), 90-110% (SG(90-110)), and more than 110% (SG(> 110)). Then, mean SBP and DBP in each subgroup of the WD, MD and UD groups were compared with the corresponding blood pressure values of each other to evaluate the effect of socioeconomic status on the blood pressure. In addition, the SBP and DBP of each subgroup were compared with other subgroups within that group to evaluate the effect of BMI on blood pressure.

RESULTS

The BMI and BMI% of the UD group were significantly lower than that of the WD and MD groups (P < 0.05). In addition, the number of children with a BMI of more than 95% for their age was significantly lower in the UD group compared with the WD and MD groups (1.7, 1.9 and 0.5% in the WD, MD and UD groups, respectively, P < 0.05). The SBP and DBP were positively correlated with BMI% in each group and in all of the subjects cumulatively (r = 0.26, P < 0.001 for SBP and r = 0.34, P < 0.001 for DBP). The SBP and DBP were significantly higher in SG(> 110) than in SG(90-110) and were also higher in SG(90-110) than in SG(< 90) in each group. Mean DBP values in all subgroups of the MD and UD groups were significantly lower than the respective subgroups of the WD group. The SBP of SG(< 90) and SG(90-110) of the UD group were significantly lower than those of the corresponding subgroups of the WD and MD groups.

CONCLUSION

Obesity is not more prevalent among the children of lower socioeconomic classes in Turkey as a developing country. In addition, independent of anthropometric structure, DBP and SBP were shown to be related to the socioeconomic status in childhood age groups and both values were determined to decrease in accordance with a decrease in the socioeconomic level.

Longitudinal correlates of change in blood pressure in adolescent girls

The objective of this study was to assess the longitudinal changes in blood pressure in black and white adolescent girls and evaluate potential determinants of changes in blood pressure, including sexual maturation and body size. A total of 1213 black and 1166 white girls, ages 9 or 10 years at study entry, were followed up through age 14 with annual measurements of height, weight, skinfold thickness, stage of sexual maturation, systolic and diastolic blood pressures, and other cardiovascular risk factors. Average blood pressures in black girls were generally 1 to 2 mm Hg higher than in white girls of similar age over the course of the study. Age, race, stage of sexual maturation, height, and body mass index (kg/m2) were all significant univariate predictors of systolic and diastolic blood pressures in longitudinal regression analyses. Black girls had a significantly smaller increase in blood pressure for a given increase in body mass index compared with white girls. The predicted increases in blood pressure per unit increase in body mass index (mm Hg per kg/m2) were as follows: systolic, 0.65+/-0.04 in whites and 0.52+/-0.04 in blacks (P<.001); diastolic fourth Korotkoff phase, 0.31+/-0.04 in whites and 0.15+/-0.03 in blacks (P<.001); and diastolic fifth Korotkoff phase, 0.31+/-0.05 in whites and 0.16+/-0.04 in blacks (P<.001). Understanding of the determinants of the racial differences in blood pressure could provide the rationale for future interventions to reduce the excess cardiovascular mortality in black compared with white women.

Inhibition of 11-beta-hydroxysteroid dehydrogenase in pregnant rats and the programming of blood pressure in the offspring

Recent epidemiological studies have linked low birth weight with the later occurrence of cardiovascular and metabolic disorders, particularly hypertension. We have proposed that fetal exposure to excess maternal glucocorticoids may underpin this association. Normally, the fetus is protected from maternal glucocorticoids by placental 11beta-hydroxysteroid dehydrogenase (11beta-HSD). We have previously shown that treatment of pregnant rats with dexamethasone, a synthetic glucocorticoid that is poorly metabolized by the enzyme, reduces birth weight and produces elevated blood pressure in the adult offspring. Moreover, low activity of placental 11beta-HSD correlates with low birth weight in rats. Here, we show that maternal administration of carbenoxolone, a potent inhibitor of 11 beta-HSD, throughout pregnancy leads to reduced birth weight (mean 20 percent decrease) and elevated blood pressures (increase in mean arterial pressure, 9 mm Hg in males, 7 mm Hg in females) in the adult offspring of carbenoxolone-treated rats. This effect requires the presence of maternal adrenal products, as carbenoxolone given to adrenalectomized pregnant rats had no effect on birth weight or blood pressure. These data support the hypothesis that excess exposure of the fetoplacental unit to maternal glucocorticoids reduces birth weight and programs subsequent hypertension and indicate a key role for placental 11beta-HSD in controlling such exposure.

Blood pressure measurement in childhood epidemiological studies

BACKGROUND

Accurate measurement of blood pressure in childhood epidemiological studies requires standardized conditions, valid instruments, and multiple measurements.

METHODS AND RESULTS

We used published literature and our own data to make recommendations on the reduction of biases caused by various technical factors, to discuss the advantages and disadvantages of selected measurement devices, and to evaluate the optimal number of visits and measurements per visit for accurate estimation of a child's blood pressure level. The conditions under which blood pressure is measured should be standardized. This includes training and certification to minimize observer biases; equipment factors such as use of an appropriate cuff bladder size, subject factors such as minimizing activities before and during the reading, environmental factors such as accounting for the time of day and ambient temperature, and technique factors such as recording both the fourth and fifth Korotkoff sounds. The choice of instrument for measuring blood pressure depends on the goals of the study and the resources available to the investigators.

CONCLUSIONS

Although relatively economical and easy to use, the standard mercury sphygmomanometer is subject to the bias resulting from knowledge of earlier readings. The random-zero sphygmomanometer overcomes this bias, but it is more expensive and difficult to use and may underestimate blood pressure levels. In contrast to auscultatory devices, automated oscillometric devices are not subject to observer biases. They are gaining wider use and may be especially appropriate for younger children. However, they are expensive, and each model requires validation before use in epidemiological studies. Ambulatory blood pressure monitoring represents a potentially useful technique for future epidemiological studies. Multiple measurements are vital in estimating a child's blood pressure, and the number of visits, days or weeks apart, is at least as important as the number of measurements per visit.

Effect of calcium supplementation on blood pressure in children

OBJECTIVE

To evaluate the effect of calcium supplementation on blood pressure in children.

DESIGN

Randomized, double-masked, placebo-controlled trial.

SETTING AND PARTICIPANTS

One hundred one fifth-grade students in one inner-city school.

INTERVENTION

Each child consumed 480 ml of juice beverages, containing either no calcium or 600 mg calcium (as calcium citrate malate) daily for 12 weeks.

MEASUREMENTS

At baseline we obtained nutrient data from three sets of 2-day food records on each subject. We measured blood pressure four times on each of three weekly sittings at baseline and at follow-up. Using multiple linear regression analysis, we compared mean blood pressure change in the intervention group with that in the placebo group.

RESULTS

There were 50 girls and 51 boys; 61 subjects were black. At baseline, mean age was 11.0 years, systolic and diastolic blood pressures were 101.7 and 57.7 mm Hg, daily total energy intake was 1966 kcal, and calcium intake was 827 mg. With control for age, height, hours of television watched, and baseline blood pressure, systolic blood pressure increased 1.0 mm Hg in the intervention group and 2.8 mm Hg in the placebo group (effect estimate = -1.8 mm Hg; 95% confidence interval -4.0, 0.3). In black subjects the intervention effect estimate was -2.0 mm Hg (95% confidence interval -4.4, 0.4). From lowest to highest quartile of baseline calcium intake (per 1000 kcal), the intervention effect estimates were -3.5, -2.8, -1.3, and 0.0 mm Hg (p for trend = 0.009). There was little effect on diastolic blood pressure.

CONCLUSION

These data suggest a blood pressure-lowering effect of calcium supplementation in children, especially in subjects with low baseline calcium intake.

Assessment of nutrition and physical activity education programmes in children

1. Studies in children relating blood lipids to the extent of atherosclerosis at post-mortem suggest a link between risk factors for cardiovascular disease in childhood and adult life. Tracking of blood pressure (BP) and cholesterol from childhood also supports this association. However, prospective studies have not yet established the outcome in children with increased levels of risk factors. 2. In a controlled trial in Perth, Western Australia, involving over 1000 10-12 year old children, fitness was improved by physical activity programmes which were associated with a greater fall in diastolic BP and triceps skinfolds in girls compared with controls. Sugar intake decreased in boys and fat intake fell in girls, mainly affecting participants in home nutrition programmes. 3. In higher risk children, identified by cluster analysis, major benefits were associated with the fitness and home nutrition programmes. Physical activity combined with involvement of the family in nutrition education is likely to be the most successful approach to modifying lifestyle in children, including those with higher levels of risk. 4. Undernutrition by too rigid restriction of fat intake must be avoided in young children who need calorie-dense foods. Undernutrition, in itself, may predispose to cardiovascular disease in later life. Programmes should aim to establish a prudent diet appropriate to the age of the child combined with physical activity. As regular activity and a healthy diet in adult life will reduce risks of cardiovascular disease it is likely that childhood education will establish lifestyle habits of potential long-term benefit.

Hypertension in pediatric patients: current issues

OBJECTIVE

To present current information on the diagnosis, treatment, and epidemiologic features of hypertension in children.

DESIGN

The guidelines published by the Task Force on Blood Pressure Control in Children in 1987 are critically evaluated, and more recent data are discussed.

RESULTS

Prevention of the consequences of hypertension necessitates recognition of the condition. Although hypertension in the pediatric age-group is an uncommon finding, it does exist. The diagnosis is based on careful technique, repetitive blood pressure measurements, and comparison with established norms. Normal blood pressure values for children have been derived from a series of large cross-sectional studies. Although they have certain shortcomings, they are useful. Height and weight are important determinants in the use of the normative data. The selection of a blood pressure cuff that completely encircles the arm is crucial. Tracking--the persistence of systolic and diastolic pressures at stable percentiles--is not a constant finding, but children at risk for development of hypertension as adults may be identifiable. As in the adult population, children with hypertension have no signs or symptoms that clearly distinguish primary from secondary hypertension.

CONCLUSION

Treatment of children with hypertension should be individualized. Etiologic evaluation is probably best performed at referral centers.

Identifying children at high risk for the development of essential hypertension

BACKGROUND AND OBJECTIVES

Because blood pressure (BP) tracks from childhood to adulthood, some have recommended screening to identify children at high risk for the development of essential hypertension as adults. Others, however, have argued against this strategy because they believe that correlations between childhood and adulthood BP levels are too low. To address these issues, we considered prediction of adult BP from childhood levels.

DESIGN

Cohort study with follow-up of participants from childhood to early adulthood.

SETTING AND PARTICIPANTS

We ascertained BP in 337 schoolchildren from East Boston, Mass., and reexamined 317 (94%) of them 8 to 12 years later, at ages 18 to 26 years. MEASUREMENTS AND DATA ANALYSIS: On each of several visits, 1 week apart (four for children, three for adults), we obtained three BP readings with a random-zero sphygmomanometer. To calculate correlation coefficients (tracking correlations) between childhood and adult BP, we assumed a multivariate normal distribution and used an iterative maximal likelihood approach in a longitudinal model. We then used these correlations in expressions for sensitivity and specificity of childhood BP as a screening test and for positive predictive value for adult BP above specified cutoff points.

RESULTS

During the 8- to 12-year interval, tracking correlations, corrected for within-person variability and adjusted for age, sex, smoking, and medication and alcohol use, were 0.55 for systolic BP and 0.44 for diastolic BP. The corresponding positive predictive values indicated that, for example, the probability that a 20-year-old man's true systolic BP will be > 139 mm Hg (> 90th percentile) was 0.44, given that his observed average systolic BP at age 10 years was > 95th percentile (> 117 mm Hg). The sensitivity of a 10-year old boy's systolic BP > 95th percentile to detect systolic BP > 139 mm Hg 10 years later was 0.17. The specificity of his BP < 95th percentile at age 10 years to detect systolic BP < 139 mm Hg at age 20 years was 0.97. For diastolic BP, predictive values and sensitivities were somewhat lower.

CONCLUSIONS

After correction for within-person variability, tracking correlations from childhood to early adulthood are higher than previously reported. However, the resulting sensitivities and predictive values for childhood BP as a screening test for adult BP are of only modest magnitude. These data call into question the usefulness of routine BP measurement to identify children at high risk for the development of essential hypertension.