Definition of pediatric hypertension: are blood pressure measurements on three separate occasions necessary?

Prevalence of childhood hypertension and associated factors in Zhejiang Province: a cross-sectional analysis based on random forest model and logistic regression

With childhood hypertension emerging as a global public health concern, understanding its associated factors is crucial. This study investigated the prevalence and associated factors of hypertension among Chinese children. This cross-sectional investigation was conducted in Pinghu, Zhejiang province, involving 2,373 children aged 8-14 years from 12 schools. Anthropometric measurements were taken by trained staff. Blood pressure (BP) was measured in three separate occasions, with an interval of at least two weeks. Childhood hypertension was defined as systolic blood pressure (SBP) and/or diastolic blood pressure (DBP) ≥ age-, sex-, and height-specific 95th percentile, across all three visits. A self-administered questionnaire was utilized to collect demographic, socioeconomic, health behavioral, and parental information at the first visit of BP measurement. Random forest (RF) and multivariable logistic regression model were used collectively to identify associated factors. Additionally, population attributable fractions (PAFs) were calculated. The prevalence of childhood hypertension was 5.0% (95% confidence interval [CI]: 4.1-5.9%). Children with body mass index (BMI) ≥ 85th percentile were grouped into abnormal weight, and those with waist circumference (WC) > 90th percentile were sorted into central obesity. Normal weight with central obesity (NWCO, adjusted odds ratio [aOR] = 5.04, 95% CI: 1.96-12.98), abnormal weight with no central obesity (AWNCO, aOR = 4.60, 95% CI: 2.57-8.21), and abnormal weight with central obesity (AWCO, aOR = 9.94, 95% CI: 6.06-16.32) were associated with an increased risk of childhood hypertension. Childhood hypertension was attributable to AWCO mostly (PAF: 0.64, 95% CI: 0.50-0.75), followed by AWNCO (PAF: 0.34, 95% CI: 0.19-0.51), and NWCO (PAF: 0.13, 95% CI: 0.03-0.30). Our results indicated that obesity phenotype is associated with childhood hypertension, and the role of weight management could serve as potential target for intervention.

Screening and Management of Pediatric High Blood Pressure-Challenges to Implementing the Clinical Practice Guideline

PURPOSE OF REVIEW

Elevated blood pressure (BP) and hypertension in childhood convey risk for hypertension and cardiovascular events in adulthood. Early recognition of abnormal BPs is key to preventing or lessening this risk. However, the process for making the diagnosis of hypertension is complex, and overall adherence to the 2017 American Academy of Pediatrics Clinical Practice Guidelines (CPG) is poor. We will review obstacles to adherence to the CPG and approaches designed to improve the diagnosis and management of hypertension in children.

RECENT FINDINGS

Baseline data from the multi-center quality improvement intervention, "Boosting Primary Care Awareness and Treatment of Hypertension" (BP-CATCH), demonstrate that childhood hypertension remains underdiagnosed. Other studies confirm a lack of compliance with the process outlined in the CPG. The provision of electronic prompts, coaching, and education results in modest improvements. The combination of embedded medical record tools and education seems to offer the most hope for improvement.

Environments affect blood pressure in toddlers: The Japan Environment and Children's Study

BACKGROUND

The primary objective of this study was to examine risk factors for toddler's hypertension.

METHODS

Subjects of this study were children and parents participating in a national birth cohort study in Japan, the Japan Environment and Children's Study. We measured the children's blood pressure (BP) at 2 and 4 years old. We obtained children's and parents' backgrounds from the questionnaire. We investigated the factors that affect BP elevation.

RESULTS

Within 4988 participants, the mean systolic BP at 2 years old was 91.2 mmHg for boys and 90.0 mmHg for girls. The mean systolic BP at 4 years old was 93.8 mmHg for boys and 93.1 mmHg for girls. Parental smoking was associated with elevated values of BP at 2 and 4 years old. Obesity, gestational hypertension, and parental lower education were associated with elevated values of BP at 4 years old. Hypertensive group had a significantly higher obesity rate. The mother's lower education and parental smoking were involved in hypertensive groups.

CONCLUSION

Parental smoking had a significant effect on BP even in early toddlers. We emphasize the importance of avoiding second-hand smoking from early infancy to prevent future lifestyle-related illnesses including hypertension.

IMPACT

The mean systolic BP at 2 years old was 91.2 mmHg for boys and 90.0 mmHg for girls. The mean systolic BP at 4 years old was 93.8 mmHg for boys and 93.1 mmHg for girls. Obesity, parental smoking, and lower education were associated with hypertension at 4 years old. Parental smoking was associated with hypertension at 2 and 4 years old. We emphasize the importance of avoiding second-hand smoking from early infancy.

Cardiovascular Risk Assessment of Elevated Blood Pressure for Screening and Early Detection in Children 6 to 9 Years of Age in the Valencian Community: ANIVA Study

Elevated blood pressure (EBP), hypertension (HT), and prehypertension (PHT), along with the rising prevalence of overweight/obesity in children, correlate with a heightened risk of cardiovascular complications. This study focuses on assessing the prevalence of overweight/obesity and EBP and identifying potential indicators for effective early screening and detection of EBP in children aged 6 to 9 years old. This cross-sectional study was conducted with 1142 students from different schools across the Valencian Community in Spain. Data collection involved administering a questionnaire alongside direct anthropometric measurements of each student. The collected data underwent comprehensive statistical analysis, including frequencies, percentages, means, and chi-square automatic interaction detector (CHAID) analysis. In the sample, 7.5% of the children had HT and 6.8% had PHT, meaning 14.3% presented with EBP. Additionally, 17.0% of the children were classified as overweight and 3.9% as obese. Body mass index >23.1, body fat percentage >20.79%, and Kidmed scores <8 were identified as potential markers for early detection of EBP. The study reveals a significant incidence of EBP and overweight/obesity. Implementing screening protocols for early detection of EBP is imperative to forestall future cardiovascular events. Moreover, lifestyle modifications emerge as the most crucial approach for managing these risk factors.

Change in Prevalence of Hypertension among Korean Children and Adolescents during the Coronavirus Disease 2019 (COVID-19) Outbreak: A Population-Based Study

During the coronavirus disease 2019 (COVID-19) outbreak, the prevalence of obesity increased globally; this may be associated with hypertension incidence. However, investigations on the changes in the prevalence of hypertension among children and adolescents are limited. This cross-sectional study investigated the prevalence of hypertension among 1428 youths aged 10-18 years using data from the Korea National Health and Nutrition Examination Survey 2018-2020. We assessed the prevalence of hypertension according to sex, age, body mass index (BMI), and residential district. The prevalence of hypertension increased from 7.1% to 12.5% in all participants. In the sex-specific analysis, the prevalence was found to be increased in boys. In the age-specific analysis, the prevalence was found to be increased in youths aged 13-15 years. In the BMI-specific analysis, an increase in the prevalence was prominent in the normal BMI group. In the residential district-specific analysis, the prevalence of hypertension among youth increased in urban areas. Our results show that the prevalence of hypertension increased among Korean children and adolescents during the COVID-19 outbreak. These findings suggest the importance of close monitoring of hypertension among youth during the COVID-19 pandemic.

Joint statement for assessing and managing high blood pressure in children and adolescents: Chapter 1. How to correctly measure blood pressure in children and adolescents

The joint statement is a synergistic action between HyperChildNET and the European Academy of Pediatrics about the diagnosis and management of hypertension in youth, based on the European Society of Hypertension Guidelines published in 2016 with the aim to improve its implementation. The first and most important requirement for the diagnosis and management of hypertension is an accurate measurement of office blood pressure that is currently recommended for screening, diagnosis, and management of high blood pressure in children and adolescents. Blood pressure levels should be screened in all children starting from the age of 3 years. In those children with risk factors for high blood pressure, it should be measured at each medical visit and may start before the age of 3 years. Twenty-four-hour ambulatory blood pressure monitoring is increasingly recognized as an important source of information as it can detect alterations in circadian and short-term blood pressure variations and identify specific phenotypes such as nocturnal hypertension or non-dipping pattern, morning blood pressure surge, white coat and masked hypertension with prognostic significance. At present, home BP measurements are generally regarded as useful and complementary to office and 24-h ambulatory blood pressure for the evaluation of the effectiveness and safety of antihypertensive treatment and furthermore remains more accessible in primary care than 24-h ambulatory blood pressure. A grading system of the clinical evidence is included.

Pediatric body mass index trajectories and the risk of hypertension among adolescents in China: a retrospective cohort study

BACKGROUND

The impact of pediatric body mass index (BMI) trajectories on the risk of adolescent hypertension (HTN) determined by three separate visits remains unclear. This longitudinal study aims to identify potential pediatric sex-specific BMI trajectories and to assess their associations with HTN and HTN subtypes.

METHODS

Based on the Health Promotion Program for Children and Adolescents (HPPCA) in Suzhou, China, a total of 24,426 participants who had initial normal blood pressure (BP) and had at least four BMI measurements during 2012-2020 were included. HTN was defined as simultaneously having three separate visits of elevated BP in 2020. Latent class growth models were used to explore sex-specific BMI trajectories, whose associations with HTN and HTN subtypes were further examined by logistic regression.

RESULTS

The incidence of HTN determined through three separate visits was 3.34%. Four trajectories were identified for both sexes: low BMI increasing, medium BMI increasing, high BMI increasing, and highest BMI increasing. Compared to the medium BMI increasing group, the odds ratio (95% confidential interval) for developing adolescent HTN of the low, high, and highest BMI increasing groups among boys were 0.54 (0.39, 0.75), 1.90 (1.44, 2.51), and 2.89 (1.90, 4.39), respectively; and the corresponding values for girls were 0.66 (0.48, 0.90), 2.30 (1.72, 3.09), and 4.71 (3.06, 7.26). Similar gradually elevated associations between different trajectories with isolated systolic hypertension, systolic and diastolic hypertension were observed.

CONCLUSION

Current results emphasized the adverse effects of stable high BMI on HTN and the benefits of maintaining normal weight throughout childhood.

Hypertension in Children and Young Adults

Primary hypertension (PH) is most common during adolescence with increasing prevalence globally, alongside the epidemic of obesity. Unlike in adults, there are no data on children with uncontrolled hypertension and their future risk of hard cardiovascular and cerebrovascular outcomes. However, hypertension in childhood is linked to hypertensive-mediated organ damage (HMOD) which is often reversible if treated appropriately. Despite differing guidelines regarding the threshold for defining hypertension, there is consensus that early recognition and prompt management with lifestyle modification escalating to antihypertensive medication is required to ameliorate adverse outcomes. Unfortunately, many unknowns remain regarding pathophysiology and optimum treatment of childhood hypertension.

Blood pressure levels among children in rural Uganda: results from 1913 children in a general population survey

Despite increasing levels of adult hypertension in sub-Saharan Africa (SSA), there is limited information on elevated blood pressure among children in SSA. We described the distribution of blood pressure among children in rural Uganda and estimated hypertension prevalence. We conducted a cross-sectional study in south-western Uganda, collecting demographic, anthropometric and blood pressure measurements from children aged 6-12 years. Children with elevated blood pressure (systolic and/or diastolic blood pressure greater or equal to the 95th percentile for age, height and sex) were invited for two further assessments 6-18 months later. We described blood pressure distribution at first assessment, assessed associations with demographic and anthropometric characteristics and estimated prevalence of hypertension as defined by having elevated blood pressure on three separate occasions months apart. Blood pressure (BP) was measured in 1913 children (50% male, 3% overweight or obese, 22% stunted) at the first assessment. Mean (SD) systolic and diastolic BP at first assessment was 113.4 mmHg (±10.8) and 69.5 mmHg (±8.3), respectively, and 44.2% had elevated BP. Older age, higher BMI, and being female were associated with higher BP, and stunted height was associated with lower BP. An estimated 7.8% [95% CI:(6.6-9.1)], (males: 6.8%, females: 9.0%), had elevated BP on three separate occasions, and were considered hypertensive. High blood pressure levels among adults in SSA may be set early in life. In this study, obesity (a common lifestyle modifiable risk factor in other settings) was largely irrelevant. More research is needed to understand the main drivers for elevated blood pressure in SSA further.

Comparisons of tri-ponderal mass index and body mass index in discriminating hypertension at three separate visits in adolescents: A retrospective cohort study

OBJECTIVE

To estimate whether the new obesity indicator tri-ponderal mass index (TMI) has a better capacity to predict adolescent hypertension (HTN) and HTN subtypes at three separate blood pressure (BP) visits than the conventionally used body mass index (BMI).

METHODS

A total of 36,950 adolescents who had initial normal BP from 2012 to 2019 were included in Suzhou, China. HTN was defined as having three separate visits of elevated BP in 2020. The area under the receiver-operating characteristic curve (AUC), false-positive rate, false-negative rate, total misclassification rates, net reclassification improvement (NRI), and integrated discrimination improvement were calculated to compare the discriminative ability of HTN between BMI and TMI.

RESULTS

TMI had better predictive abilities than BMI among all of the participants when predicting HTN (difference in AUC = 0.019, 95% CI = 0.007-0.031; NRI = 0.067, 95% CI = 0.008-0.127) and isolated systolic hypertension (difference in AUC = 0.021, 95% CI = 0.005-0.036; NRI = 0.106, 95% CI = 0.029-0.183). The difference in prediction abilities between BMI and TMI was more obvious in the subgroup of age ≥16. Also, TMI outperformed BMI in predicting adolescent HTN in girls but not in boys.

CONCLUSION

Compared with BMI, TMI may have a better predictive capacity for HTN, particularly in girls and older adolescents. TMI has the potential to be used as an effective predictor for HTN in clinic practice. Further studies are needed to verify the utility of TMI.

Breastfeeding Duration and High Blood Pressure in Children and Adolescents: Results from a Cross-Sectional Study of Seven Provinces in China

This study was aimed to investigate the associations between breastfeeding duration and blood pressure (BP) levels, BP Z scores and high BP (HBP) in children and adolescents. A total of 57,201 participants including 29,491 boys and 27,710 girls aged 7−18 years were recruited from seven provinces in China in 2012. HBP was defined as BP levels of ≥95th percentiles of the referent age-, sex-, and height-specific population. Breastfeeding duration was divided into non-breastfeeding, 0−5 months, 6−12 months, and >12 months. Information on demographic, parental or family factors and dietary behaviors was collected through a self-administered questionnaire. Multivariable linear regression and logistic regression models were applied to assess the relationships of breastfeeding duration with BP levels and BP Z scores and with HBP, respectively. Stratified analyses were performed to further investigate the potential subgroup-specific associations. The reported prolonged breastfeeding (>12 months) rate was 22.53% in the total population. After full adjustment, compared to the non-breastfeeding group, breastfeeding for 6−12 months was correlated with 0.43 (95% CI: −0.75, −0.11) and 0.36 (95% CI: −0.61, −0.12) mmHg lower levels of SBP and DBP, respectively. Similar decrease trends were found for BP Z scores. Prolonged breastfeeding (>12 months) was associated with 1.33 (95% CI: 1.12, 1.58) and 1.12 (95% CI: 0.94, 1.33) higher odds of HBP in boys and girls, respectively. Based on nationally representative data, there was no evidence that a longer duration of breastfeeding is protective against childhood HBP. Breastfeeding for 6−12 months may be beneficial to BP, while prolonged breastfeeding durations might increase the odds of HBP in children and adolescents.

Prevalence of hypertension and hypertension phenotypes after three visits in Chinese urban children

OBJECTIVE

This study aims to evaluate the prevalence of hypertension and hypertension subtypes among Chinese children aged 6-17 years in a multicenter school-based sample by three separate screenings.

METHODS

Students from six major cities in China (Changchun, Beijing, Jinan, Shanghai, Chongqing, and Chengdu) were recruited in this cross-sectional survey during 2012 and 2015. Each participant was seated and had three consecutive blood pressure measurements on the right arm in the morning by an automated oscillometric device and the hypertensive ones were followed to the next visit. Hypertension was diagnosed by BP references for Chinese children and adolescents in 2010.

RESULTS

Data from 44 396 children aged 6-17 years were included in analysis, 50.9% of whom were boys. The prevalence of confirmed hypertension after three separate screenings was 4% in the total population, 5% in boys, and 3% in girls, respectively. The prevalence of confirmed isolated systolic hypertension (ISH), isolated diastolic hypertension (IDH), and systolic and diastolic hypertension (SDH) in the total population was 2.7, 0.3 and 1%, respectively.

CONCLUSION

Around 4% urban Chinese children and adolescents aged 6 -17 years were hypertensive after three separate BP screenings in 2012 -2015. ISH was the most frequent form of hypertension in children.

High Blood Pressure and Changes in the Body Mass Index Category Among Japanese Children: A Follow-Up Study Using the Updated American Academy of Pediatrics Guidelines

Background

High blood pressure (HBP) has become a public health issue worldwide. The relationship between high BP and changes in the body mass index (BMI) category in Japanese pubertal children has not yet been examined. To resolve this issue, we examined existing data with a focus on the primordial prevention of high BP signs, including elevated BP, among pubertal children aged 12 and 15 years.

Methods

Height, body weight, and BP data were examined from health checkups of 18,247 children conducted between 1993 and 2000 in the Karatsu Study, which was a cohort of pediatric lifestyle-related disease prevention medical health checkups in Japan. BP and BMI were assessed using the updated American Academy of Pediatrics (AAP) guidelines and Endocrine Society’s clinical practice guidelines definitions, respectively.

Results

Follow-up data were obtained from 7,090 subjects (50.5% boys). Stage 2 hypertension (HTN) was detected in 3% and 2.7% of boys and girls aged 12 years, respectively, and in 2.7% and 1% of boys and girls aged 15 years, respectively. Among children aged 15 years, 1.4% were newly classified with stage 2 hypertension, and 15.6% exhibited improvements to a normal BP. A binomial logistic regression analysis of high BP and BMI category changes revealed odds ratios (OR) in the group with a deteriorated BMI category of 1.51 (95% confidence interval (CI), 1.17-1.94), 2.30 (95%CI, 1.66-3.17), and 6.83 (95%CI, 4.14-11.29) for elevated BP, stage 1 hypertension, and stage 2 hypertension, respectively.

Conclusion

High BP in puberty positively correlated with BMI category changes. Considering the presence of the tracking phenomenon in hypertension, BP monitoring is an essential part of the early strategy for the prevention of lifestyle-related diseases in childhood, and improvements in BP control are crucial in early life.

The Importance of Office Blood Pressure Measurement Frequency and Methodology in Evaluating the Prevalence of Hypertension in Children and Adolescents With Type 1 Diabetes: The SWEET International Database

OBJECTIVE

The prevalence of hypertension is higher in children and adolescents with type 1 diabetes (T1D) compared with those without. This retrospective analysis of a large cohort of children and adolescents with T1D from the SWEET (Better control in Pediatric and Adolescent diabeteS: Working to crEate CEnTers of Reference) international consortium of pediatric diabetes centers aimed to 1) estimate the prevalence of elevated office blood pressure (BP) and hypertension and 2) investigate the influence of BP measurement methodology on the prevalence of hypertension.

RESEARCH DESIGN AND METHODS

A total of 27,120 individuals with T1D, aged 5-18 years, were analyzed. Participants were grouped into those with BP measurements at three or more visits (n = 10,440) and fewer than 3 visits (n = 16,680) per year and stratified by age and sex. A subgroup analysis was performed on 15,742 individuals from centers providing a score indicating BP measurement accuracy.

RESULTS

Among participants with BP measurement at three or more visits, the prevalence of hypertension was lower compared with those with fewer than three visits (10.8% vs. 17.5% P < 0.001), whereas elevated BP and normotension were higher (17.5% and 71.7% vs. 15.3% and 67.1%, respectively; both P < 0.001). The prevalence of hypertension and elevated BP was higher in individuals aged ≥13 years than in younger ones (P < 0.001) and in male than female participants (P < 0.001). In linear regression models, systolic and diastolic BP was independently determined by the BP measurement methodology.

CONCLUSIONS

The estimated prevalence of elevated BP and hypertension in children and adolescents with T1D is ∼30% and depends on the BP measurement methodology. Less frequent BP evaluation may overestimate the prevalence of hypertension.

Pediatric hypertension based on Japanese Society of Hypertension Guidelines (JSH 2019) with actual school blood pressure screening data in Japan

Blood pressure (BP) in children and adolescents is associated with their growth. BP is most strongly associated with height during height gain and with degree of obesity after reaching final height. BP in childhood and adolescence is correlated with BP in adulthood. The pathophysiology of pediatric essential hypertension is associated with obesity, excess salt intake, and a low birth weight. The common causes of pediatric secondary hypertension are renal parenchymal and renovascular diseases. The significance of diagnosing pediatric hypertension involves detecting secondary hypertension and preventing organ damage due to hypertension as well as tracking essential hypertension in adulthood. Appropriate BP measurement procedures are required for diagnosing pediatric hypertension. The inflatable bladder of an appropriately sized cuff should exceed 40% of the arm circumference. BP measurements should be performed consecutively at least 3 times using an appropriately sized cuff. The diagnosis of hypertension requires that all BP values measured on 3 or more occasions be above the reference value. The criteria for pediatric hypertension are determined based on the distribution of BP in healthy children and adolescents, with values above the 95th percentile of normal representing hypertension. Japanese criteria define pediatric hypertension as ≥120/70 mmHg for preschool children, ≥130/80 mmHg for 1st-3rd graders, ≥135/80 mmHg for 4th-6th graders, ≥140/85 mmHg for 7th-9th grade boys, ≥135/80 mmHg for 7th-9th grade girls, and ≥140/85 mmHg for senior high school boys and girls. The prevalence of Japanese pediatric hypertension was 0.9% based on proper measurement protocols. The basis of managing pediatric essential hypertension is healthy lifestyle modifications. Pharmacotherapy is indicated for persistent hypertension, symptomatic hypertension, secondary hypertension, the development of target organ damage, the presence of chronic kidney disease, and diabetes mellitus. Screening for pediatric hypertension is important; therefore, BP should be routinely measured in children and adolescents.

Screening for hypertension in young people with obesity: Feasibility in the real life

BACKGROUND AND AIM

Screening for pediatric hypertension (HTN) is based on several measurements of blood pressure (BP) in different visits. We aimed to assess its feasibility in outpatient youths with overweight/obesity (OW/OB) in terms of adherence to two-repeated measurements of BP and to show the features of youths who missed the follow-up and the predictive role of clinical and/or anamnestic features on confirmed HTN.

METHODS AND RESULTS

Six hundred, eighty-eight youths (9-17 years) with OW/OB, consecutively recruited, underwent a first measurement of BP. Those exhibiting BP levels within the hypertensive range were invited to repeat a second measurement within 1-2 weeks. Confirmed HTN was diagnosed when BP in the hypertensive range was confirmed at the second measurement. At entry, 174 youths (25.1%) were classified as hypertensive. At the second visit, 66 youths (37.9%) were lost to follow-up. In the remaining 108 participants, HTN was confirmed in 59, so that the prevalence of confirmed HTN was 9.5% in the overall sample; it was higher in adolescents than children (15.9% vs 6.8%, P = 0.001). HTN at first visit showed the best sensitivity (100%) and a good specificity (91%) for confirmed HTN. The association of HTN at first visit plus familial HTN showed high specificity (98%) and positive predictive value of 70%.

CONCLUSION

The high drop-out rate confirms the real difficulty to obtain a complete diagnostic follow up in the obese population. Information about family history of HTN may assist pediatricians in identifying those children who are at higher risk of confirmed HTN.

Prevalence of hypertension and related risk factors among children and adolescents at three separate visits: A large school-based study in China

OBJECTIVE

We aimed to demonstrate characteristics of hypertension at three separate visits and its risk factors among children and adolescents based on a large school-based study in China.

MATERIALS AND METHODS

Based on a large-scale ongoing monitoring program conducted in Suzhou, China, 59,679 children and adolescents aged 7-17 years from 60 public schools were enrolled during 2020 to 2021. Height, weight, and blood pressure (BP) were measured. Additional BP would be measured for hypertensive students at least 2 weeks later. Confirmed hypertension was defined as simultaneously BP meeting above or equal to 95th percentile for age, sex, and height at three separate visits. Odds ratio (ORs), and 95% CIs were calculated by logistic regression to identify risk factors for hypertension.

RESULTS

Prevalence of hypertension at three separate visits were 20.4, 6.3, and 3.1%, respectively. Prevalence of confirmed isolated systolic hypertension, isolated diastolic hypertension, and systolic and diastolic hypertension were 1.9, 0.3, and 0.9%, respectively. Hypertension prevalence for stages 1 and 2 were 2.6 and 0.6%. Different hypertension prevalence were found among various age and gender groups. Boys [OR, 1.137 (95% CI, 1.033-1.251)], high age [OR, 3.326 (95% CI, 2.950-3.751)], urban residents [OR, 1.579 (95% CI, 1.417-1.760)], high-socioeconomic status [OR, 1.156 (95% CI, 1.039-1.286)] and body mass index category including overweight [1.883 (95% CI, 1.665-2.129)], obesity [4.049 (95% CI, 3.625-4.523)], and thinness [OR, 0.457 (95% CI, 0.306-0.683)] were associated with confirmed hypertension.

CONCLUSION

A single BP measurement would overestimate hypertension prevalence, about 3% Chinese children were hypertensive, early, and effective intervention around risk factors for hypertension should be taken.

Identification of Potential Metabolic Markers of Hypertension in Chinese Children

Background

Studies in adults have shown that several metabolites across multiple pathways are strongly associated with hypertension. However, as yet, to our knowledge, no study has investigated such association in childhood. We, therefore, compared the serum metabolite profile of children with normal and elevated blood pressure (BP) to identify potential metabolic markers and pathways that could be useful for the assessment of pediatric hypertension.

Methods

The study included 26 hypertensive children (age range, 6-11 years) and 26 age- and sex-matched ones with normal BP, who were recruited from the baseline survey of the Huantai Childhood Cardiovascular Health Cohort Study. Ultrahigh-performance liquid chromatography-quadrupole time-of-flight-mass spectrometry was performed to assess the serum metabolite profile. Logistic regression analysis was used to select significant metabolites associated with hypertension after adjustment for body mass index, waist circumference, and lipid profile. Kyoto Encyclopedia of Genes and Genomes (KEGG) and MetaboAnalyst were utilized to search for the potential pathways of metabolites.

Results

A total of 45 and 34 metabolites were preliminarily screened in positive and negative modes, respectively (variable importance in the projection (VIP) > 1.0 and P < 0.05). After adjustment for the false discovery rate, 7 and 1 differential metabolites in the positive and negative modes, respectively, remained significant (VIP > 1.0 and q < 0.05). These metabolites were mainly involved in amino acid metabolism and glycerophospholipid metabolism. Among these, two significant metabolites including ethanolamine and 2-methyl-3-hydroxy-5-formylpyridine-4-carboxylate displayed an area under the curve value of 0.820 (95% confidence interval, 0.688-0.951), with a sensitivity of 0.846 and a specificity of 0.769.

Conclusion

The untargeted metabolomics approach effectively identified the differential serum metabolite profile in children with and without hypertension. Notably, two metabolites including ethanolamine and 2-methyl-3-hydroxy-5-formylpyridine-4-carboxylate exhibited a good discriminative ability to identify children with hypertension, providing new insights into potential mechanisms of pediatric hypertension.

Utility of blood pressure measurements at an initial screening visit to identify Chinese children and adolescents with hypertension

The performance of different BP readings and their combinations at a visit to identify children and adolescents with pediatric hypertension remains controversial. We aimed to assess the utility of different blood pressure (BP) readings and their combinations obtained at the initial screening visit for identifying Chinese children and adolescents with hypertension. Participants were 7831 children and adolescents aged 6‐17 years measured as part of a cross‐sectional survey conducted in Jinan, China between September 2012 and November 2014. BP was measured three times at up to three visits. Elevated BP at the initial visit was defined as systolic BP and/or diastolic BP ≥ age‐ and sex‐specific 95th percentiles using the Chinese BP references for children and adolescents based on different BP readings and their combinations. Participants with elevated BP using (BP2+BP3)/2 across three visits were defined as having hypertension. Of the different readings or combinations examined, the mean of the last two readings at the initial visit had the best predictive utility for children and adolescents with hypertension (sensitivity: 100.0%; specificity: 86.9%; positive predictive value: 27.6%; negative predictive value: 100.0%). This was also reflected in the area under the curve being highest for the mean of the last two readings (0.93, 95% confidence interval: 0.93‐0.94) compared with any of the other readings or combinations (BP1, BP2, BP3, [BP1+BP2]/2, [BP1+BP3]/2, and [BP1+BP2+BP3]/3; all p < .001). Taking three measurements of BP and using the average of the last two readings at a screening visit may be optimal for the identification of hypertension in youth.

Blood pressure measurement methodology and technology in the SWEET diabetes centers: An international SWEET database survey

INTRODUCTION

The accuracy of blood pressure (BP) measurement is a prerequisite for the reliable diagnosis and management of hypertension.

OBJECTIVES

This survey evaluated the use of office and out-of-office BP measurements and the antihypertensive pharmacological treatment in expert pediatric diabetes centers.

METHODS

A questionnaire was distributed in 78 reference pediatric diabetes centers of the SWEET international consortium. The methodology, devices, indications, and interpretation of office BP measurements (OBPM), 24-hour ambulatory BP monitoring (ABPM) and home BP monitoring (HBPM), and the preference for antihypertensive drug treatment was assessed. A grading score was developed to evaluate centers for overall BP measurement performance.

RESULTS

Fifty-two centers responded. The average score for OBPM methodology was 72.5%, for technology 77.5% and the overall center score was 74.75%.The majority of the centers used appropriate methodology and technology, however, there was heterogeneity among them. Manual auscultatory or automated devices specifically validated for children were used by 26/52 centers. ABPM was recommended by 35/52 centers (27/35 had health insurance coverage) and HBPM by 18/52 centers. The BP measurement methodology and devices used for ABPM and HBPM were frequently inadequate. Angiotensin converting enzyme inhibitors were the most frequently prescribed drugs for treating hypertension.

CONCLUSIONS

The majority of SWEET pediatric diabetes centers use adequate methodology and devices for BP measurement. ABPM is recommended by two thirds of the centers, whereas HBPM is less widely used. Further improvement in the quality of office and out-of-office BP measurements and harmonization among centers is necessary according to current guidelines.

Evidence Gaps in the Identification and Treatment of Hypertension in Children

The ultimate goal of recognizing and treating hypertension in childhood is to prevent target-organ damage during childhood and to reduce the risk of adulthood cardiovascular disease. The quality of evidence to guide blood pressure management in children is lower than in adult medicine, yet some common findings support clinical practice recommendations. Oscillometric devices are increasingly replacing manual blood pressure measurements, but evidence shows that readings are not equivalent between the 2 methods. In addition, multiple blood pressure readings are needed before diagnosing a child with hypertension, but the optimal number and timing are still being determined. The recent American Academy of Pediatrics blood pressure guideline has revised the normative data tables and included threshold blood pressure limits which seem to identify children with higher cardiovascular risks. Threshold limits vary between guidelines, and the most accurate threshold has yet to be determined. Lifestyle modifications are a cornerstone of hypertension management, but the optimal diet and physical activity changes for beneficial effect are not known. When pharmacotherapy is needed, physicians have used drugs from all antihypertensive classes in children, yet only a few classes have been systematically studied. The long-term cardiovascular consequences of elevated blood pressure during childhood are under investigation and it seems that the lower the childhood blood pressure the better and that the rate of change during childhood is predictive of adulthood disease. With much still to learn, this article summarizes the evidence and the evidence gaps for the diagnosis, investigation, management, and outcomes of pediatric hypertension.

Multiple office blood pressure measurement: a novel approach to overcome the weak cornerstone of blood pressure measurement in children. Data from the SPA project

BACKGROUND

This contribution aims to report and analyze a novel approach for office blood pressure measurement in children.

METHODS

Healthy children 5 to 8 years of age were eligible. After 5 minutes rest, 10 unattended blood pressure readings were taken at 3-minute intervals using a validated automated oscillometric device. After discarding outlier values (< 5th or > 95th percentile of the recorded values), the coefficient of variation and the mean of the 10 readings were calculated. The single readings #1 to #10 were compared with this elaborated average of the 10 measurements.

RESULTS

Two hundred eighty-one healthy, non-obese children (137 females, 49%), median age 5.7 (IQR 5.3-6.1) years, were analyzed. The median coefficients of variation were 7% (IQR 5-9) for systolic and 4% (IQR 3-6) for diastolic blood pressure. The first 3 measurements were significantly different from the average, while the readings #4 to #10 were not. Based on the average, only nine subjects had a systolic or diastolic blood pressure > 90th centile (n = 3 > 95th percentile).

CONCLUSIONS

Although most guidelines advise three blood pressure readings, these findings suggest that in children, office blood pressure measurement might be improved by including ten measurements. In situations of time constraints, the fourth blood pressure reading might be used as a reliable approximation.

Updates to pediatric hypertension guidelines: influence on classification of high blood pressure in children and adolescents

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Objective:

The American Academy of Pediatrics updated Clinical Practice Guidelines (CPG) for screening high blood pressure (HBP) in children and adolescents in 2017. This study aimed to assess differences in HBP classification applying this updated HBP definition in a large sample of Chinese youth.

Methods:

Data from 50 336 youth aged 6–17 participating in the 2013 Chinese national survey were analyzed. HBP was diagnosed according to the established (Fourth Report) and updated (2017 CPG) definitions. The associations between HBP with BMI, height, early life factors and behavioral factors were investigated using logistic regression models.

Results:

Applying the CPG definition, 16.7% of children (6–12 years) and 7.9% of adolescents (13–17 years) had HBP, compared with 10.8 and 6.3% applying the Fourth Report definition. Prevalence estimates for HBP differed the greatest for boys, children aged 11, those with high BMI, and those of tall stature. The odds ratios (ORs) for HBP with BMI, height, hip and waist circumference, early life factors and behavioral factors were comparable for the two definitions.

Conclusion:

The new criteria for HBP in young people will lead healthcare providers to diagnose more children as hypertensive. Notably, associations between HBP with BMI and other medical and behavioral factors remained strong, supporting validity of the new definition.

Use of Static Cutoffs of Hypertension to Determine High cIMT in Children and Adolescents: An International Collaboration Study

BACKGROUND

Pediatric hypertension is typically defined as blood pressure ≥ sex-, age-, and height-specific 95th percentile (high) cutoffs. Given the number of strata, there are hundreds of cutoffs for defining elevated and high blood pressure that make it cumbersome to use in clinical practice. This study aimed to evaluate the utility of the static cutoffs for pediatric hypertension (120/80 mm Hg for children and 130/80 mm Hg for adolescents) in determining high carotid intimamedia thickness (cIMT) in children and adolescents.

METHODS

Data were from 6 population-based cross-sectional studies in Brazil, China, Greece, Italy, Spain, and the United Kingdom. A total of 4280 children and adolescents, aged 6 to 17 years, were included. High cIMT was defined as cIMT ≥ sex-, age- and cohort-specific 90th percentile cutoffs.

RESULTS

Compared with normal blood pressure, hypertension defined using the percentile-based cutoffs from 2017 American Academy of Pediatrics guideline, and the static cutoffs were associated with similar higher odds for high cIMT (percentile-based cutoffs: odds ratio [OR], 1.46, 95% confidence interval [CI], 1.15-1.86; static cutoffs: OR, 1.65, 95% CI, 1.25-2.17), after adjustment for sex, age, race/ethnicity, body mass index, high-density lipoprotein-cholesterol, triglyceride, and fasting blood glucose. The similar utility of 2 definitions in determining high cIMT was further confirmed by area under the receiver operating characteristic curve and net reclassification improvement methods (P for difference > 0.05).

CONCLUSION

Static cutoffs (120/80 mm Hg for children, 130/80 mm Hg for adolescents) performed similarly compared with percentile-based cutoffs in determining high cIMT, supporting the use of static cutoffs in identifying pediatric hypertension in clinical practice.

Global Prevalence of Hypertension in Children: A Systematic Review and Meta-analysis

IMPORTANCE

Reliable estimates of the prevalence of childhood hypertension serve as the basis for adequate prevention and treatment. However, the prevalence of childhood hypertension has rarely been synthesized at the global level.

OBJECTIVE

To conduct a systematic review and meta-analysis to assess the prevalence of hypertension in the general pediatric population.

DATA SOURCES

PubMed, MEDLINE, Embase, Global Health, and Global Health Library were searched from inception until June 2018, using search terms related to hypertension (hypertension OR high blood pressure OR elevated blood pressure), children (children OR adolescents), and prevalence (prevalence OR epidemiology).

STUDY SELECTION

Studies that were conducted in the general pediatric population and quantified the prevalence of childhood hypertension were eligible. Included studies had blood pressure measurements from at least 3 separate occasions.

DATA EXTRACTION AND SYNTHESIS

Two authors independently extracted data. Random-effects meta-analysis was used to derive the pooled prevalence. Variations in the prevalence estimates in different subgroups, including age group, sex, setting, device, investigation period, BMI group, World Health Organization region and World Bank region, were examined by subgroup meta-analysis. Meta-regression was used to establish the age-specific prevalence of childhood hypertension and to assess its secular trend.

MAIN OUTCOMES AND MEASURES

Prevalence of childhood hypertension overall and by subgroup.

RESULTS

A total of 47 articles were included in the meta-analysis. The pooled prevalence was 4.00% (95% CI, 3.29%-4.78%) for hypertension, 9.67% (95% CI, 7.26%-12.38%) for prehypertension, 4.00% (95% CI, 2.10%-6.48%) for stage 1 hypertension, and 0.95% (95% CI, 0.48%-1.57%) for stage 2 hypertension in children 19 years and younger. In subgroup meta-analyses, the prevalence of childhood hypertension was higher when measured by aneroid sphygmomanometer (7.23% vs 4.59% by mercury sphygmomanometer vs 2.94% by oscillometric sphygmomanometer) and among overweight and obese children (15.27% and 4.99% vs 1.90% among normal-weight children). A trend of increasing prevalence of childhood hypertension was observed during the past 2 decades, with a relative increasing rate of 75% to 79% from 2000 to 2015. In 2015, the prevalence of hypertension ranged from 4.32% (95% CI, 2.79%-6.63%) among children aged 6 years to 3.28% (95% CI, 2.25%-4.77%) among those aged 19 years and peaked at 7.89% (95% CI, 5.75%-10.75%) among those aged 14 years.

CONCLUSIONS AND RELEVANCE

This study provides a global estimation of childhood hypertension prevalence based on blood pressure measurements in at least 3 separate visits. More high-quality epidemiologic investigations on childhood hypertension are still needed.

Impact of Birth Weight and Length on Primary Hypertension in Children

BACKGROUND

A child's birth parameters not only enable assessment of intrauterine growth but are also helpful in identifying children at risk of developmental defects or diseases occurring in adulthood. Studies show that children born with a body weight that is small for their gestational age (SGA) are at a greater risk of hypertension though the inverse relation between excessive birth weight and the risk of primary hypertension in children is discussed less frequently.

PURPOSE

To assess the impact of both birth weight and length on hypertension occurring in children aged 3-15 years.

METHODS

A total of 1000 children attending randomly selected primary schools and kindergartens were examined. Ultimately, the analyses took into account n = 747 children aged 4-15; 52.6% boys and 47.4% girls. The children's body height and weight were measured; their blood pressure was examined using the oscillometric method. Information on perinatal measurements was retrieved from the children's personal health records.

RESULTS

Compared to the children with small for gestational age (SGA) birth weight, the children with appropriate for gestational age birth weight (AGA) (odds ratio (OR) 1.31; 95% confidence interval (CI) 0.64-2.65) present greater risk for primary hypertension. Infants born with excessive body weight >4000 g irrespective of gestational age, compared to infants born with normal body weight, show increased risk of primary hypertension (OR 1.19; 95% CI 0.68-2.06). Higher risk of hypertension is observed in infants born with greater body length (OR 1.03; 95% CI 0.97-1.08).

CONCLUSIONS

The problem of hypertension may also affect children with birth weight appropriate for gestational age. The prevalence of hypertension in children with AGA birth weight decreases with age. Birth length can be a potential risk factor for hypertension in children and adolescents.

Selective Blood Pressure Screening in the Young: Quantification of Population Wide Underestimation of Elevated Blood Pressure

Universal blood pressure (BP) screening in children and adolescents is questioned in prevention guidelines, while measuring blood pressure in the young in the context of overweight, obesity, or parental hypertension is promoted. This study quantifies with population data the underestimation of elevated blood pressure that would result from limiting BP screening only to those with overweight, obesity, or parental hypertension in the young. Selective screening was simulated with representative national health examination data from Germany (age 3-17, N=14,633, KiGGS0 study 2003-2006; age 18-39, N=1,884, DEGS1 2008-2011 study), with mean of two oscillometric measurements on one occasion; cutoffs for hypertensive BP in children were the 95th percentile using KiGGS percentiles, and for sensitivity analyses Fourth Report percentiles, in adults 140/90 mmHg; childhood overweight and obesity were classified according to the International Obesity Task Force and for adults as BMI ≥25 and ≥30 kg/m2. In 3-17-year-olds, different selective BP screening scenarios were simulated: screening only in those with obesity, overweight, parental hypertension, combination of overweight and parental hypertension, resulting in screening 5.6%, 20.0%, 28.5%, and 42.6% of the population and detecting 17.2%, 38.6%, 30.3%, and 58.2% of all hypertensive cases in the population. In conclusion our results show a large screening gap that would result from selective BP screening only in those with overweight, obesity, or parental hypertension.

Features of and preventive measures against hypertension in the young

The Japanese hypertension guidelines report that essential hypertension is detected in 1–3% of upper elementary and high school students during blood pressure (BP) screenings. Hypertension in these age groups is an emerging public health concern mainly attributed to the rising rate of pediatric obesity. Considering the existence of BP tracking phenomenon, early preventive education and instruction are necessary, especially for male students with moderately elevated BP showing a tendency toward obesity, despite the low prevalence of hypertension in high school students. Students with a positive family history of hypertension and those born with low birth weight need the same measures. Lifestyle habits, such as increased alcohol intake, dramatically change once students begin university; thus, early education and instruction regarding the factors influencing BP are necessary. In particular, for male students with higher BP during high school, caution regarding increased body weight is required irrespective of their level of obesity. Young adults aged <40 years should be educated about the association between body weight and hypertension. Particular caution surrounding lifestyle habits, including drinking and smoking, is warranted in male hypertensive subjects because hypertension at a young age is strongly associated with obesity. BP monitoring and the management of obesity should be considered efficient approaches to the detection and treatment of hypertension. For the lifetime prevention of hypertension, it is essential to be aware of one’s health status and learn about healthy lifestyles beginning in childhood. BP measurement may be an appropriate means to achieve this goal.

Hypertension Prevalence Based on Three Separate Visits and Its Association With Obesity Among Chinese Children and Adolescents

Background: Clinical practice guidelines recommended that hypertension in children and adolescents should be defined based on elevated blood pressure (BP) on at least three separate occasions. Therefore, in the present study, we aimed to estimate the prevalence of hypertension based on three separate visits among Chinese children and adolescents and to examine its relationship with obesity. Methods: A school-based cross-sectional survey was performed in children and adolescents in Jinan, China between September 2012 and September 2014. A total of 7,832 children and adolescents aged 6-17 years were included. Anthropometric data and BP were measured by trained examiners. Elevated BP was defined as BP ≥ 95th percentile for age and sex based on the Chinese reference data. Participants with elevated BP at the first visit underwent a second visit 2 weeks later, and a third visit was conducted if BP was still high at the second visit. Hypertension was defined as having an elevated BP at all three visits. Obesity was defined in three ways by using body mass index, waist circumference, and waist-to-height ratio. Results: The prevalence of elevated BP decreased substantially across three separate visits, with the prevalence of 17.2, 8.6, and 4.9%, respectively. Obesity was an independent risk factor for elevated BP during each visit. Based on the body mass index, obesity was associated with higher risk of elevated BP, with the adjusted odds ratios (ORs) and 95% confidence intervals (CIs) of 8.6 (6.8-11.0), 12.5 (9.1-17.3), and 14.0 (8.9-22.2), respectively, at the first, second and third visit. The ORs of elevated BP were similar in association with obesity defined by waist circumference or waist-to-height ratio. Conclusions: The prevalence of hypertension based on three visits was ~5% in Chinese children and adolescents. There was a dose-response relationship between obesity and elevated BP across three visits.

Height-specific blood pressure cutoffs for screening elevated and high blood pressure in children and adolescents: an International Study

Pediatric blood pressure (BP) reference tables are generally based on sex, age, and height and tend to be cumbersome to use in routine clinical practice. In this study, we aimed to develop a new, height-specific simple BP table according to the international child BP reference table based on sex, age and height and to evaluate its performance using international data. We validated the simple table in a derivation cohort that included 58,899 children and adolescents aged 6-17 years from surveys in 7 countries (China, India, Iran, Korea, Poland, Tunisia, and the United States) and in a validation cohort that included 70,072 participants from three other surveys (China, Poland and Seychelles). The BP cutoff values for the simple table were calculated for eight height categories for both the 90th ("elevated BP") and 95th ("high BP") percentiles of BP. The simple table had a high performance to predict high BP compared to the reference table, with high values (boys/girls) of area under the curve (0.94/0.91), sensitivity (88.5%/82.9%), specificity (99.3%/99.7%), positive predictive values (93.9%/97.3%), and negative predictive values (98.5%/97.8%) in the pooled data from 10 studies. The simple table performed similarly well for predicting elevated BP. A simple table based on height only predicts elevated BP and high BP in children and adolescents nearly as well as the international table based on sex, age, and height. This has important implications for simplifying the detection of pediatric high BP in clinical practice.

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.

Secular Trends in Blood Pressure and Overweight and Obesity in Chinese Boys and Girls Aged 7 to 17 Years From 1995 to 2014

The current study aimed to assess the secular trends in overweight and obesity status and high blood pressure (HBP) in Chinese children and adolescents for 2 decades. Data on 943 128 participants aged 7 to 17 years were obtained from the Chinese National Survey on Students' Constitution and Health from 1995 to 2014. The population attributable risk of overweight status for HBP was calculated. The prevalence of overweight increased from 4.3% in 1995 to 18.4% in 2014, whereas HBP prevalence fluctuated in the range of 4.4% to 6.4% during the same time period, the lowest in 2005. Within each survey year, blood pressure levels and HBP prevalence increased with higher body mass index. Notably, the population attributable risk of HBP because of being overweight steadily increased from 6.3% in 1995 to 19.2% in 2014. The same trends of linear growth for obesity, fluctuating blood pressure, and its sustained increasing population attributable risk for overweight also occurred among the domestic 29 provinces. Despite dramatic increases in overweight prevalence among Chinese children from 1995 to 2014, the HBP prevalence remained relatively stable, suggesting that other independent factors are affecting HBP trends to a greater extent. Yet, over time, the magnitude of the impact of being overweight or obese on HBP increased sharply, predicting looming heavy burden of HBP. Reductions in overweight status may aid in preventing HBP so as to prevent coronary risk in adulthood.