Relationship of home blood pressure with target-organ damage in children and adolescents

Reliability of systolic blood pressure measured by parents in young children at home using a hand held doppler device and aneroid sphygmomanometer

OBJECTIVE

We report data regarding systolic BP monitoring in children aged <5 years performed over a 2-week period by parents at home using a hand-held doppler device and aneroid sphygmomanometer for SBP measurements (HDBPM). Our objectives were to compare health professional measured office systolic BP by doppler device (Office-SBP Doppler ) with parent measured home systolic BP using the same doppler device (Home-SBP Doppler ). We also report data evaluating reliability and optimal number of days of measurement required.

DESIGN AND METHODS

We taught parents to measure systolic BP and assessed their technique using a hand-held doppler device and aneroid sphygmomanometer. We requested parents to perform three consecutive BP measurements twice daily (ideally morning and evening around similar times) when the child was awake, settled and cooperative.

RESULTS

Over a 3-year period, data from 48 of 62 children who underwent HDBPM measurements were evaluated with median (IQR) age of 1.9 (0.9, 3.6) years, 27 (56%) boys and 14 (29%) on antihypertensive medication. Office-SBP Doppler was 2.9 ± 8.9 mmHg [95% confidence interval (CI), -14.4 to 20.4, P  = 0.026] higher than Home-SBP Doppler . Mean Home-SBP Doppler between Week-1 and Week-2 monitoring was similar -0.45 ± 3.5 mmHg (95% CI, -7.35 to 6.45, P  = 0.41). Morning HDBPM measurements were lower than evening with a mean difference of -2.77 ± 3.92 mmHg, P  < 0.001). Over Week-1, mean Home-SBP Doppler was closer to mean Office-SBP Doppler with increasing cumulative days of monitoring and with smaller standard deviations suggesting that readings become more reliable from day 4 onwards.

CONCLUSIONS

HDBPM is a reliable method for measuring systolic BP in young children with BP levels measured by parents comparable to those performed by health professional in clinic. HDBPM technique described here and performed by parents over a 7-day period with a minimum of 4-days, offers a reliable and reproducible technique to measure blood pressure at home.

Reduced Blood Pressure Dipping Is A Risk Factor for the Progression of Chronic Kidney Disease in Children

Background: Elevated blood pressure and proteinuria are well-established risk factors for chronic kidney disease (CKD) progression in children. This study aimed to analyze risk factors for CKD progress, emphasizing detailed ambulatory blood pressure (ABPM) data. Methods: In 55 children with CKD II−V, observed for ≥1 year or until initiation of kidney replacement therapy, we analyzed ABPM, clinical, and biochemical parameters. Results: At the beginning, the glomerular filtration rate (eGFR) was 66 (interquartile range—IQR: 42.8−75.3) mL/min/1.73 m2, and the observation period was 27 (16−36) months. The mean eGFR decline was 2.9 ± 5.7 mL/min/1.73 m2/year. eGFR decline correlated (p < 0.05) with age (r = 0.30), initial proteinuria (r = 0.31), nighttime systolic and mean blood pressure (r = 0.27, r = 0.29), and systolic and diastolic blood pressure dipping (r = −0.37, r = −0.29). There was no relation between mean arterial pressure during 24 h (MAP 24 h Z-score) and eGFR decline and no difference in eGFR decline between those with MAP 24 h < and ≥50 th percentile. In multivariate analysis, systolic blood pressure dipping (beta = −0.43), presence of proteinuria (beta = −0.35), and age (beta = 0.25) were predictors of eGFR decline. Conclusions: Systolic blood pressure dipping may be a valuable indicator of CKD progression in children.

Variation in paediatric 24-h ambulatory blood pressure monitoring interpretation by Canadian and UK physicians

Twenty-four-hour ambulatory blood pressure monitoring (ABPM) is widely accepted as a more accurate method for measurement of blood pressure (BP) compared to a single office-based measurement of BP. However, it is unclear how physicians interpret ABPM and make management decisions. This study's goal is to investigate variation in ABPM interpretation among paediatric nephrologists (Canada and UK) and paediatric cardiologists (Canada only) via an online survey. The survey content included baseline demographics, questions on the use and indications for ABPM, interpretation of results, and subsequent management decisions in various clinical scenarios. The survey was sent to 196 Canadian physicians, with 69 (35.2%) total responses. Thirty-five UK clinicians also completed the survey. Most respondents were >44 years old, were in practice for at least 11 years, and were university-based. There were substantial differences among clinicians in ABPM interpretation for isolated systolic, diastolic, and night-time hypertension. For example, only 53.1% of physicians would initiate or modify treatment in those with diastolic HTN in CKD. Further, even for the same abnormal ABPM parameter, the decision to start or alter treatment was influenced by the underlying medical condition. There is significant variation in clinical practice among physicians for interpretation and management of hypertension when using ABPM. Differences in guidelines among various jurisdictions, as well as knowledge gaps in the research on which guidelines are based, create ambiguity regarding ABPM interpretation and management decisions. A more protocolized approach and further insight into the reasoning behind the variation in physicians' interpretation may help to standardise practice.

Association of blood pressure, obesity and physical activity with arterial stiffness in children: a systematic review and meta-analysis

Central pulse wave velocity (cPWV) is a biomarker for cardiovascular (CV) risk and a predictor for CV events in adulthood. Alterations of arterial stiffness have also been associated with CV risk in childhood. The study aimed to systematically review and meta-analyze the association of blood pressure (BP), body mass index (BMI), and cardiorespiratory fitness (CRF) with cPWV in children. Literature search was through the databases PubMed, Web of Science, Embase and the Cochrane Register of Controlled Trials. Twenty-two articles were included in the systematic review and eight articles in the meta-analysis. Higher systolic and diastolic BP were associated with higher cPWV (pooled estimated effect size (ES) 0.02 (95% CI: 0.012-0.027; P < 0.001), and ES 0.02 (95% CI: 0.011-0.029; P < 0.001); respectively). Higher BMI correlated with higher cPWV (ES 0.025 (95% CI: 0.013-0.038; P < 0.001)). CRF was inversely associated with cPWV (ES -0.033 (95% CI: -0.055 to -0.011; P = 0.002)). In children, higher BP and BMI are already related to increased cPWV, and enhanced CRF may be a preventive strategy to counteract development of CV disease later in life. IMPACT: This meta-analysis suggests that elevated blood pressure and body mass index in childhood correlate with increased central pulse wave velocity. Children with higher cardiorespiratory fitness appear to have favorably lower arterial stiffening. Elevated blood pressure and altered arterial stiffness originate early in life and childhood risk stratification as well as timely initiation of exercise treatment may help counteract development of manifest cardiovascular disease later in life.

Comparison of China Reference with Different National and International References: The Prevalence of High Blood Pressure in 695,302 Children and Adolescents in a Metropolis of Yangtze River Delta, China

Objectives

This study aimed to compare performances of China reference and different national references on high blood pressure (HBP).

Methods

A cross-sectional study including 695,302 children and adolescents aged 7 to 17 years in Suzhou, China, was conducted to determine the prevalence of HBP based on U.S., international, Europe, and China references in 2016.

Results

Different percentiles of height and blood pressure were found among four references. Referring to U.S. reference, the prevalence of HBP was the highest with 26.0%, followed by International reference with 20.0%, Europe reference with 19.5%, and China reference with 19.2%. McNemar tests indicated statistically significant differences between HBP prevalence comparing China reference with the other 3 references (P < 0.001). The area under the curve was 0.947, 0.851, and 0.949 for U.S., international, and Europe reference, respectively. U.S. reference showed the highest sensitivity (98.2%), but the lowest specificity (91.2%), and Europe reference showed the highest kappa value (0.893).

Conclusions

The prevalence of HBP varied among these four references, and the appropriate choice of reference would be important to recognize high-risk children and judge the trends of HBP prevalence in the targeted population.

Nighttime Home Blood Pressure in Children: Association with Ambulatory Blood Pressure and Preclinical Organ Damage

[Figure: see text].

Pediatric Obesity, Hypertension, Lipids

PURPOSE OF REVIEW

The rise of the pediatric obesity pandemic over the past 40 years has sharpened focus on the management of obesity, hypertension and lipid abnormalities in children. Multiple studies demonstrate that these risk factors track from childhood into adulthood predisposing individuals to premature atherosclerotic cardiovascular disease and putting them at risk for early morbidity and mortality.

RECENT FINDINGS

Importantly, obesity, hypertension and lipid problems are individual risk factors that can occur independently. Multiple studies have shown that each risk factor causes target organ damage in children. Intensive and focused lifestyle modifications can improve a child's subclinical disease and decrease the risk for future morbidity.

SUMMARY

Childhood offers a unique opportunity at primordial and primary prevention of atherosclerotic cardiovascular disease. Clinicians must focus on targeting these highly prevalent conditions and applying lifestyle modification and then pharmacologic or surgical therapies as needed.

Subclinical Organ Damage in Children and Adolescents with Hypertension: Current Guidelines and Beyond

High blood pressure (BP) is becoming a growing health issue even in children and adolescents. Moreover, BP elevation in youth frequently translates into children and adult hypertension contributing to the development of cardiovascular disease. The detection of early markers of vascular damage, potentially leading to overt cardiovascular disease, is important for clinical decisions about if and how to treat hypertension and can be useful in monitoring the effectiveness of the treatment. The purpose of this review is to summarize the actual knowledge about subclinical organ damage (SOD) in hypertensive children and adolescents and its association with cardiovascular disease in children and young adults. Our focus is especially put on left ventricular mass, pulse wave velocity, carotid intima-media thickness and microalbuminuria. We also want to address the scientific evidence about possible regression of SOD and cardiovascular risk with the use of behavioural and specific anti-hypertensive therapy. Indications from current guidelines are critically discussed.

Home Blood Pressure Monitoring in Children and Adolescents: Systematic Review of Evidence on Clinical Utility

PURPOSE OF REVIEW

For the accurate diagnosis and management of hypertension, out-of-office blood pressure evaluation using ambulatory (ABPM) or home monitoring (HBPM) is currently recommended. In children, there is considerable evidence on the clinical utility of ABPM, whereas the evidence on HBPM is limited. This systematic review presents (i) the benefits of HBPM in children; (ii) the evidence on normal range, diagnostic accuracy, and relationship with preclinical organ damage; and (iii) guidance for devices, monitoring schedule, and interpretation.

RECENT FINDINGS

HBPM is a useful adjunct to the conventional office measurements for the evaluation of children with suspected or treated hypertension. HBPM is feasible in children and has good reproducibility, diagnostic accuracy and acceptability by users, and relatively low cost. Thus, it has greater potential for widespread and long-term use than ABPM, which is more expensive and often not available or not tolerated. Automated monitors that have been clinically validated specifically in children should be used with appropriate cuff size. HBPM for 7 days (minimum 3) with duplicate morning and evening measurements (minimum 12 readings) should be performed in children with suspected or treated hypertension before each office visit. Until more data become available, in case of diagnostic disagreement between office blood pressure and HBPM, treatment decisions should be based on ABPM. HBPM is clinically useful in children with hypertension. More research is needed on its clinical application, and more automated devices need to be clinically validated in this population.

Home blood pressure monitoring in pediatric hypertension: the US perspective and a plan for action

The 2017 US guidelines for pediatric hypertension place considerable emphasis on blood pressure measurements, which are the cornerstone for hypertension diagnosis and management. It is recognized that when the diagnosis of hypertension is based solely on office blood pressure measurements, many children are misclassified (over- or underdiagnosed). Therefore, out-of-office blood pressure evaluations using ambulatory or home blood pressure monitoring are often necessary to obtain an accurate diagnosis. Strong evidence for the diagnostic and clinical value of ambulatory blood pressure monitoring in children has justified its central role in decision making in recent pediatric recommendations. However, ambulatory blood pressure monitoring is not widely accessible in primary care. There is little evidence for home blood pressure monitoring in children, yet this method is widely available and feasible for the evaluation of elevated blood pressure in children. This article presents a case for using home blood pressure monitoring for the management of children with suspected or treated hypertension in clinical practice in comparison to using office measurements or ambulatory blood pressure monitoring, as well as its optimal application. More research on home blood pressure monitoring in children is urgently needed.

Utility of arterial stiffness assessment in children

Atherosclerotic cardiovascular disease is a leading cause of death and disability worldwide, and the atherosclerotic process begins in childhood. Prevention or containment of risk factors that accelerate atherosclerosis can delay the development of atherosclerotic cardiovascular disease. Although current recommendations are to periodically screen for commonly prevailing risk factors for atherosclerosis in children, a single test that could quantify the cumulative effect of all risk factors on the vasculature, thus assessing arterial health, would be helpful in further stratifying risk. Measurement of pulse wave velocity and assessment of augmentation index - measures of arterial stiffness - are easy-to-use, non-invasive methods of examining arterial health. Various studies have assessed pulse wave velocity and augmentation index in children with commonly occurring conditions including obesity, hypertension, insulin resistance, diabetes mellitus, dyslipidaemia, physical inactivity, chronic kidney disease, CHD and acquired heart diseases, and in children who were born premature or small for gestational age. This article summarises pulse wave velocity and augmentation index assessments and the effects of commonly prevailing chronic conditions on arterial health in children. In addition, currently available reference values for pulse wave velocity and augmentation index in healthy children are included. Further research to establish widely applicable normative values and the effect of lifestyle and pharmacological interventions on arterial health in children is needed.

2016 European Society of Hypertension guidelines for the management of high blood pressure in children and adolescents

Increasing prevalence of hypertension (HTN) in children and adolescents has become a significant public health issue driving a considerable amount of research. Aspects discussed in this document include advances in the definition of HTN in 16 year or older, clinical significance of isolated systolic HTN in youth, the importance of out of office and central blood pressure measurement, new risk factors for HTN, methods to assess vascular phenotypes, clustering of cardiovascular risk factors and treatment strategies among others. The recommendations of the present document synthesize a considerable amount of scientific data and clinical experience and represent the best clinical wisdom upon which physicians, nurses and families should base their decisions. In addition, as they call attention to the burden of HTN in children and adolescents, and its contribution to the current epidemic of cardiovascular disease, these guidelines should encourage public policy makers to develop a global effort to improve identification and treatment of high blood pressure among children and adolescents.

Performance of blood pressure to height ratio as a screening tool for elevated blood pressure in rural children: Ellisras Longitudinal Study

There are complications in diagnosing hypertension in children and adolescents due to variation of blood pressure (BP) values to age, gender and height. This study was aimed at assessing whether the performance of BP-to-height ratio (BPHR) can be an effective tool for screening prehypertension and hypertension in Ellisras Longitudinal Study (ELS) children aged between 6 and 17 years. A number of the 9002 children aged 6-17 years who were part of the ELS underwent height and BP measurements using standard procedures. Receiver-operating characteristic curve was used to assess the accuracy of BPHR to screen children with prehypertension and hypertension. The optimal systolic BPHR (SBPHR) and diastolic BPHR (DBPHR) cut-off points for hypertension were determined. Sensitivity/specificity, positive predictive values and negative predictive values were calculated. The optimal thresholds for defining prehypertension was 0.77 in children aged 6-10 years and 0.73 in adolescents aged between 11 and 17 years for systolic BPHR and 0.55 in children and 0.53 in adolescents for diastolic BPHR, respectively. The corresponding values for hypertension stage 1 were 0.76 and 0.73 for SBPHR and 0.50 and 0.58 for DBPHR, respectively. BPHR can be used as an effective tool for screening both prehypertension and hypertension in ELS children aged 6-17 years.

A systems-based approach to managing blood pressure in children following kidney transplantation

Hypertension is one of the most common and well-known complications following kidney transplantation in children. Yet, despite numerous available therapies many pediatric kidney transplant recipients continue to have poorly controlled blood pressure, suggesting that traditional approaches to blood pressure management in this population might be inadequate. Over the last two decades, the Chronic Care Model has been developed to improve chronic illness outcomes through delivery system design and clinical information systems that support patient self-management and provider decision-making. In this educational review we discuss key elements of managing blood pressure following pediatric kidney transplantation and suggest ways that they may be reliably implemented into clinical practice using principles from the Chronic Care Model.

Novelty in hypertension in children and adolescents: focus on hypertension during the first year of life, use and interpretation of ambulatory blood pressure monitoring, role of physical activity in prevention and treatment, simple carbohydrates and uric acid as risk factors

The present article intends to provide an update of the article "Focus on prevention, diagnosis and treatment of hypertension in children and adolescents" published in 2013 (Spagnolo et al., Ital J Pediatr 39:20, 2013) in this journal. This revision is justified by the fact that during the last years there have been several new scientific contributions to the problem of hypertension in pediatric age and during adolescence. Nevertheless, for what regards some aspects of the previous article, the newly acquired information did not require substantial changes to what was already published, both from a cultural and from a clinical point of view. We felt, however, the necessity to rewrite and/or to extend other parts in the light of the most recent scientific publications. More specifically, we updated and extended the chapters on the diagnosis and management of hypertension in newborns and unweaned babies, on the use and interpretation of ambulatory blood pressure monitoring, and on the usefulness of and indications for physical activity. Furthermore, we added an entirely new section on the role that simple carbohydrates (fructose in particular) and uric acid may play in the pathogenesis of hypertension in pediatric age.

Arterial stiffness and SBP variability in children and adolescents

BACKGROUND

The aim of this study was to explore the impact of ambulatory blood pressure (ABP) parameters on arterial stiffness measured by carotid-femoral pulse wave velocity (cf-PWV) in children and adolescents.

METHOD

The study population consisted of 138 consecutive young patients (age range 4-20 years) referred to our hypertension center. Office blood pressure (BP), 24-h ABP monitoring and cf-PWV measurements were performed in all patients. Family history and smoking habits were also recorded.

RESULTS

Among the study population, 10.6% had cf-PWV values equal to or higher than the 95th percentile of the study population. cf-PWV was higher in the hypertensive compared to the normotensive patients, classified by ABP levels even after adjustment for age and sex. Significant correlations were found between cf-PWV and age, weight, height, estimated central pulse pressure (PP), office SBP and DBP, and ABP parameters including 24-h SBP and DBP, weighted 24-h SBP variability, 24-h SBP and DBP load, 24-h mean arterial pressure (MAP), daytime and night-time SBP, daytime and night-time SBP variability, but not with office and 24-h heart rate, 24-h heart rate variability, 24-h daytime and night-time PP, DBP variability, ambulatory arterial stiffeness index and BMI z-score. In analysis of covariance, only weighted 24-h SBP variability (β = 0.28, P < 0.05) and daytime SBP variability (β = 0.15, P < 0.05) were the independent determinants of cf-PWV in children and adolescents.

CONCLUSION

These data may suggest that increased SBP variability is closely associated with arterial stiffness in children and adolescents.

Relationship between maternal gestational hypertension and home blood pressure in 7-year-old children and their mothers: Tohoku Study of Child Development

Women who had hypertensive disorders in pregnancy have an increased risk of cardiovascular diseases in later life. No studies, however, have investigated whether maternal hypertensive disorders in pregnancy affect self-measured blood pressure at home (HBP) in mothers and their children. We evaluated the association between maternal hypertension during pregnancy and HBP based on the prospective Tohoku Study of Child Development birth cohort study, which was performed in two areas in Japan. We included children in a singleton birth at term (36-42 weeks of gestation) with a birth weight of >2400 g. We collected prenatal care data from the medical charts. Because only two mothers experienced preeclampsia, we defined gestational hypertension (GH) as a hypertensive disorder in pregnancy. Seven years after birth, mothers and their children measured their HBP in the morning for 2 weeks. Of 813 eligible mothers, 28 (3.4%) experienced GH, and those were of a similar age compared with 785 non-GH mothers (37.3 vs. 38.0 years; P=0.41). Women with GH had higher body mass index (BMI) (23.8 vs. 21.4 kg m(-)(2); P=0.01) and elevated HBP (120.3/76.8 vs. 110.4/68.6 mm Hg; P<0.0002) 7 years after delivery. However, HBP was similar in children with and without GH mothers (93.5/55.9 vs. 94.1/56.1 mm Hg, P>0.38). These results were confirmatory in case-control (1:2) analyses with matching by maternal age, maternal BMI before pregnancy, survey area and parity. In conclusion, maternal GH did not affect HBP in offspring but strongly affected maternal HBP even 7 years after birth.

Hypertension screening using blood pressure to height ratio

OBJECTIVES

The definition of hypertension in children is too complex to be used by medical professionals and children and their parents because of the age-, gender-, and height-specific blood pressure (BP) algorithm. The aim of this study was to simplify the pediatric BP percentile references using BP to height ratio (BPHR, equal to BP/height) for screening for prehypertension and hypertension in Chinese children.

METHODS

Data were obtained from the China Health and Nutrition Survey, which was conducted from 1991 to 2009 and included 11 661 children aged 6 to 17 years with complete data on age, gender, height, and BP values. Receiver operating characteristic curve analysis was performed to assess the performance of systolic BPHR (SBPHR) and diastolic BPHR (DBPHR) for screening for pediatric prehypertension and hypertension.

RESULTS

The optimal thresholds for defining prehypertension were 0.81 in children aged 6 to 11 years and 0.70 in adolescents aged 12 to 17 years for SBPHR and 0.52 in children and 0.46 in adolescents for DBPHR, respectively. The corresponding values for hypertension were 0.84, 0.78, 0.55, and 0.50, respectively. The negative predictive values were much higher (all ≥99%) for prehypertension and hypertension, although the positive predictive values were relatively lower, ranging from 13% to 75%.

CONCLUSIONS

BPHR index is simple and accurate for screening for prehypertension and hypertension in Chinese children aged 6 to 17 years and can be used for early screening or treating Chinese children with hypertension.

Ambulatory and home blood pressure monitoring in children and adolescents: diagnosis of hypertension and assessment of target-organ damage

The prevalence of elevated blood pressure in children and adolescents is more common than previously believed and often represents the early onset of essential hypertension, particularly in adolescents. The definition of hypertension in children is based on distribution criteria and normalcy tables that provide blood pressure percentiles for each measurement method (office, ambulatory and home) according to the individual's age, gender and body size. Owing to the white coat and masked hypertension phenomena, ambulatory blood pressure monitoring is indispensable for the diagnosis of hypertension in children. Home blood pressure monitoring in children has been less well studied, and at present, treatment decisions should not be based solely on such measurements. Hypertension-induced preclinical target-organ damage (mainly echocardiographic left ventricular hypertrophy) is not uncommon in children and should be evaluated in all hypertensive children. Other indices of target-organ damage, such as carotid intima-media thickness, pulse wave velocity and microalbuminuria, remain under investigation in pediatric hypertension.

Pediatric ambulatory blood pressure monitoring: indications and interpretations

The prevalence of hypertension in children and adolescents is increasing, especially in obese and ethnic children. The adverse long-term effects of hypertension beginning in youth are known; therefore, it is important to identify young patients who need intervention. Unfortunately, measuring blood pressure (BP) is difficult due to the variety of techniques available and innate biologic variation in BP levels. Ambulatory BP monitoring may overcome some of the challenges clinicians face when attempting to categorize a young patient's BP levels. In this article, the authors review the use of ambulatory BP monitoring in pediatrics, discuss interpretation of ambulatory BP monitoring, and discuss gaps in knowledge in usage of this technique in the management of pediatric hypertension.

Hypertension in children and adolescents

Pediatric hypertension (HTN) has become the focus of interest recently due to its increasing prevalence. This is mainly related to the increase in childhood obesity, although the current evidence suggests that other lifestyle factors, apart from obesity, contribute to high blood pressure (BP) in childhood. Traditionally, office BP measurements by the physician have been the cornerstone for the assessment of HTN in children. However, since the white coat and masked HTN phenomena are not rare in childhood, out-of-office BP measurements have significantly improved the accurate diagnosis of HTN and decision making. Ambulatory BP monitoring is regarded as indispensable for the evaluation of pediatric HTN, providing details not only for the staging for HTN, but also for the study of other ambulatory BP patterns. It should be pointed out that HTN in children and adolescents is associated with target-organ damage which is significant in terms of cardiovascular risk. The current knowledge, outlined in the present review, is expected to help in early and accurate diagnosis as well as in the management of HTN in children and adolescents.