Prevalence of hypertension in schoolchildren based on repeated measurements and association with overweight

Hemorrhagic stroke in children

Hemorrhagic stroke (HS) in childhood accounts for almost 50% of childhood strokes, is among the top ten causes of deaths, or determines lifelong disability. These facts form significant socio-economic and demographic problems. The purpose of this review is to analyze current knowledge about HS in children. The data on HS terminology are presented, taking into account the International Classification of Diseases 11 edition. Attention is paid to the epidemiology of HS in children, including the results of individual local studies. The risk factors of HS in children were studied with an analysis of the causal, pathophysiological mechanisms of HS of various etiologies. The ideas about the clinical manifestations of HS in children are described. The analysis of HS treatment in children was carried out with an emphasis on achievements in neurointensive therapy of the acute period of HS. This review also includes information on the outcomes of HS in children.

The association of obesity and hyperuricemia with ambulatory blood pressure in children

BACKGROUND

Primary hypertension (HTN) in children is on the rise and linked to the childhood obesity epidemic. Recent studies support the role of hyperuricemia in the pathogenesis of HTN. With this study we intend to evaluate the effect of body mass index (BMI) and uric acid levels on daily blood pressure (BP) parameters/phenotypes and target organ damage (TOD).

METHODS

A mean ambulatory systolic and/or diastolic BP ≥ 95th percentile or above the adolescent cut points was defined as 'HTN'. Patients were grouped as group 1 normal weight, and group 2 overweight/obese.

RESULTS

Of the 140 children (89 male/51 female) with a mean age of 13.9 ± 2.6 years, 21 were overweight and 86 were obese. Mean 24-h systolic BP (SBP) and daytime SBP were higher in group 2 (p = 0.015, p = 0.011). BMI was positively correlated with 24-h SBP (r = 0.272, p = 0.001) and daytime SBP (r = 0.280, p = 0.001). Uric acid level showed a moderate correlation with daytime SBP (r = 0.311, p < 0.01). Logistical regression analysis showed that daytime SBP is independently associated with obesity (OR 7.44, 95%CI 2.7-20.6, p < 0.001) and male sex (OR 4.60, 95%CI 2.0-10.2, p < 0.001), but not uric acid. Left ventricular hypertrophy was more common in non-dippers (p = 0.044).

CONCLUSIONS

Male sex and BMI are independently associated risk factors for systolic BP. The association between non-dipping pattern and TOD suggests the widespread use of ambulatory blood pressure monitoring (ABPM) in childhood HT. In this paper, we could not demonstrate an independent association between uric acid and SBP. The effect of uric acid on SBP seems to be regulated by other metabolic factors in addition to uric acid.

Obesity and hypertension in children and adolescents

As childhood obesity rates increase worldwide, the prevalence of obesity-related hypertension is also on the rise. Obesity has been identified as a significant risk factor for hypertension in this age group. National Health Surveys and meta-analyses show increasing trends in obesity and pediatric hypertension in obese children. The diagnosis of hypertension in children involves percentiles relative to age, sex, and height, unlike in adults, where absolute values are considered. Elevated blood pressure (BP) in childhood is consistently associated with cardiovascular disease in adulthood, emphasizing the need for early detection and intervention. The pathogenesis of hypertension in obesity involves multiple factors, including increased sympathetic nervous system activity, activation of the renin-angiotensin-aldosterone system (RAAS), and renal compression due to fat accumulation. Obesity disrupts normal RAAS suppression and contributes to impaired pressure natriuresis and sodium retention, which are critical factors in the development of hypertension. Risk factors for hypertension in obesity include degree, duration, and distribution of obesity, patient age, hormonal changes during puberty, high-sodium diet, sedentary lifestyle, and socioeconomic status. Treatment involves lifestyle changes, with weight loss being crucial to lowering BP. Medications such as angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers may be considered first, and surgical approaches may be an option for severe obesity, requiring tailored antihypertensive medications that consider individual pathophysiology to avoid exacerbating insulin resistance and dyslipidemia.

Sex differences in blood pressure phenotypes over time - the HELIUS study

BACKGROUND

Hypertension can be classified into different phenotypes according to systolic and diastolic blood pressure (BP). In younger adults, these phenotypical differences have different prognostic value for men and women. However, little is known about sex differences in the natural course of different BP phenotypes over time.

METHODS

We used baseline and follow-up data from the multiethnic, population-based HELIUS study to assess differences in BP phenotypes over time in men and women aged < 45 years stratified according to baseline office BP into normotension (<140/<90 mmHg), isolated systolic hypertension (ISH, ≥140/<90 mmHg), isolated diastolic hypertension (IDH, <140/≥90 mmHg) or systolic diastolic hypertension (SDH, ≥140/≥90 mmHg). Logistic regression adjusted for age, ethnicity, and follow-up time was used to assess the risk of hypertension at follow-up (BP ≥140/90 mmHg or use of antihypertensive medication), stratified by sex.

RESULTS

We included 4103 participants [mean age 33.5 years (SD 7.4), 43.4% men] with a median follow-up time of 6.2 years. Compared to normotensive individuals, the age-adjusted odds ratios (OR) for having hypertension at follow-up were 4.78 (95% CI 2.90; 7.76) for ISH, 6.02 (95% CI 3.70; 9.74) for IDH and 33.73 (95% CI 20.35; 58.38) for SDH in men, while in women, OR were 10.08 (95% CI 4.09; 25.56) for ISH, 27.59 (95% CI 14.68; 53.82) for IDH and 50.58 (95% CI 24.78; 114.84) for SDH.

CONCLUSIONS

The risk of hypertension at follow-up was higher among women for all phenotypes compared to men, particularly in those with IDH. Findings of this study emphasize the importance of close BP monitoring in the young, especially in women.

Prevalence of hypertension and its associations with body composition across Chinese and American children and adolescents

BACKGROUND

The age of onset of hypertension (HTN) is decreasing, and obesity is a significant risk factor. The prevalence and racial disparities in pediatric HTN and the association between body composition and blood pressure are insufficiently studied. This study aimed to evaluate the prevalence of HTN in Chinese and American children and adolescents and to assess the relationship between various body composition indices and HTN.

METHODS

Seven thousand, five hundred and seventy-three Chinese and 6239 American children and adolescents aged 8-18 years from the 2013-2015 China Child and Adolescent Cardiovascular Health study and the 2011-2018 National Health and Nutrition Examination Surveys were analyzed. Blood pressure and body composition (fat and muscle) were measured by trained staff. The crude prevalence and age-standardized prevalence rate (ASPR) of primary HTN and its subtypes [isolated systolic hypertension (ISH) and isolated diastolic hypertension (IDH)] were calculated based on 2017 American Academy of Pediatrics guidelines. Multivariable-adjusted linear regression coefficients and odds ratios (ORs) were calculated to assess the associations of body composition indicators with HTN, ISH and IDH.

RESULTS

The ASPR of HTN was 18.5% in China (CN) and 4.6% in the United States (US), whereas the obesity prevalence was 7.4% and 18.6%, and the population attributable risk of HTN caused by overweight and obesity was higher in the US than in CN. Increased fat mass, muscle mass and body fat percentage mass were associated with a higher risk of HTN in both countries. The percent of muscle body mass had a protective effect on HTN and ISH in both countries [HTN (CN: OR = 0.83, 95% CI = 0.78-0.88; US: OR = 0.72, 95% CI = 0.64-0.81); ISH (CN: OR = 0.87, 95% CI = 0.80-0.94; US: OR = 0.71, 95% CI = 0.62-0.81)], and the protective effect was more common among children and adolescents with high levels of physical activity.

CONCLUSIONS

The burden of HTN in Chinese children and adolescents was substantial and much greater than that in the US, and the contribution of obesity to HTN was higher in the US than in CN. Augmenting the proportion of muscle mass in body composition has a protective effect against HTN in both populations. Optimizing body composition positively influences blood pressure in children and adolescents, particularly those with high-level physical activity. Video abstract (MP4 149982 KB).

Gender differences and climate zones in overweight and obesity prevalence in European elementary school children from 2000 to 2020: a systematic review and meta-analysis

Introduction

After 2000, there are more obese than underweight people in the world. We face a rapid increase in average global warming of 1.5°C, reported as a syndemic problem of three interconnected epidemics: obesity, global warming, and undernutrition. We aimed to analyze the impact and association between global warming and obesity in children and differences by gender across Europe after 2000.

Methods

We searched PubMed, MEDLINE, Google Scholar, ScienceDirect, and Embase databases. The considered population were children aged 6-14. Only cross-sectional studies that defined obesity by the IOTF cutoffs and the subjects' place of residence, used to determine precise climate zones, were included. We assessed the prevalence of obesity and overweight using a random-effects and the Mantel-Haenszel fixed-effect method when heterogeneity was greater/lower than 50%. We did a subgroup analysis for prevalence across gender, obesity, and overweight, two decades, regions, countries, and the Köppen-Geiger climate zones. Random effects of the meta-regression were used to study the global warming impact and differences in trends across European countries by gender for both conditions separately.

Results

We identified 114 studies that included 985,971 children from 39 European countries. A significant difference between genders was in favor of obese girls 4.78 (95% CI: 3.85-5.93) versus boys 5.76% (95% CI: 5.11-6.48, p = 0.03), respectively, but not for overweight children. Most of the obese girls were in South Europe 7.51% (95% CI: 6.61-8.51) versus East Europe 2.86% (95% CI: 23-3.12), versus boys in South Europe 8.66% (95% CI: 7.68-9.74) and North Europe 3.49% (95% CI: 2.90-4.19), respectively. The "cold" Köppen-Geiger climate zone, with lowest temperatures, has the largest trend rise between two decades of 2.8% and 1.53% for obese girls and boys, and 5.31% and 1.81% for overweight girls and boys, respectively, followed by the smallest number of obese girls 3.28% (95% CI: 2.17-4.92) and boys 3.58% (95% CI: 2.39-5.33), versus the zone with the highest temperatures "hot" for girls 7.02% (95% CI: 6.30-7.82) and for boys 8.23% (95% CI: 7.55-8.96), respectively. The meta-regression proved global warming has a significant impact on the distribution of obesity and overweight across climate zones, R2 = 0.52 and R2 = 0.22. No significant gender differences, or significant interaction, was noted.

Conclusion

Our meta-analysis provides a comprehensive overview of the association between and impact of global warming on obesity. This impact increases obesity among children in Europe throughout all climate zones, and emphasizes an urgent call for further preventive methods in schools, since obesity differences continue their trend of disappearing into the future.Systematic review registration: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021282127, identifier: CRD42021282127.

Office blood pressure versus ambulatory blood pressure measurement in childhood obesity

BACKGROUND

The prevalence of obesity-related co-morbidities is rising parallel to the childhood obesity epidemic. High blood pressure (BP), as one of these co-morbidities, is detected nowadays at increasingly younger ages. The diagnosis of elevated BP and hypertension, especially in the childhood population, presents a challenge to clinicians. The added value of ambulatory blood pressure measurement (ABPM) in relation to office blood pressure (OBP) measurements in obese children is unclear. Furthermore, it is unknown how many overweight and obese children have an abnormal ABPM pattern. In this study we evaluated ABPM patterns in a population of overweight and obese children and adolescents, and compared these patterns with regular OBP measurements.

METHODS

In this cross-sectional study in overweight or obese children and adolescents aged 4-17 years who were referred to secondary pediatric obesity care in a large general hospital in The Netherlands, OBP was measured during a regular outpatient clinic visit. Additionally, all participants underwent a 24-hour ABPM on a regular week-day. Outcome measures were OBP, mean ambulatory SBP and DBP, BP load (percentage of readings above the ambulatory 95th blood pressure percentiles), ambulatory BP pattern (normal BP, white-coat hypertension, elevated BP, masked hypertension, ambulatory hypertension), and BP dipping.

RESULTS

We included 82 children aged 4-17 years. They had a mean BMI Z-score of 3.3 (standard deviation 0.6). Using ABPM, 54.9% of the children were normotensive (95% confidence interval 44.1-65.2), 26.8% had elevated BP, 9.8% ambulatory hypertension, 3.7% masked hypertension, and 4.9% white-coat hypertension. An isolated night-time BP load > 25% was detected in almost a quarter of the children. 40% of the participants lacked physiologic nocturnal systolic BP dipping. In the group of children with normal OBP, 22.2% turned out to have either elevated BP or masked hypertension on ABPM.

CONCLUSIONS

In this study a high prevalence of abnormal ABPM patterns in overweight or obese children and adolescents was detected. Additionally, OBP poorly correlated with the child's actual ABPM pattern. Herewith, we emphasized the usefulness of ABPM as an important diagnostic tool in this population.

Bariatric surgery in the management of childhood and adolescence obesity

BACKGROUND

Nowadays, childhood obesity is literally a global pandemic health problem. According to current data, pediatric obesity is strongly associated with adult excess weight status as well as the development of certain co morbidities, already present in childhood, including cardiovascular disorders (dyslipidemia, hypertension), endocrine/metabolic (Type 2 diabetes, fatty liver disease, metabolic syndrome), respiratory, gastrointestinal, and musculoskeletal problems. Additionally, children with obesity frequently experience psychosocial issues, such as mood disorders, anxiety, prejudice and low self-esteem.

METHODS AND RESULTS

The aim of this article was to evaluate whether or not bariatric surgery is an effective and safe treatment option for childhood obesity. This paper is based on a literature search in Pub Med for articles referring to the medical co morbidities and the results of different types of bariatric surgery for the treatment of childhood obesity (up to 18 years) until December 2021. The following keywords were used as MESH terms: childhood obesity, adolescence obesity, co morbidities and bariatric surgery. The bibliographic references of the studies found in these databases were also reviewed.

CONCLUSION

Although some researchers demonstrate that surgical interventions in adolescents might be a reliable intervention to lose weight in a maintainable way and reverse many of the co morbidities associated with severe obesity, their safety and long-term efficacy are still not clarified. Thus, large long-term prospective studies, with detailed recording of complications and co morbidity resolution are obviously needed in order to determine the role of surgical treatment in childhood obesity.

Appraisal of Clinical Care Practices for Child Obesity Treatment. Part II: Comorbidities

The objective of this technical report is to provide clinicians with actionable evidence-based information upon which to make treatment decisions. In addition, this report will provide an evidence base on which to inform clinical practice guidelines for the management and treatment of overweight and obesity in children and adolescents. To this end, the goal of this report was to identify all relevant studies to answer 2 overarching key questions: (KQ1) "What are effective clinically based treatments for obesity?" and (KQ2) "What is the risk of comorbidities among children with obesity?" See Appendix 1 for the conceptual framework and a priori Key Questions.

Determining the prevalence of childhood hypertension and its concomitant metabolic abnormalities using data mining methods in the Northeastern region of Hungary

Objective

Identifying hypertension in children and providing treatment for it have a marked impact on the patients' long-term cardiovascular outcomes. The global prevalence of childhood hypertension is increasing, yet its investigation has been rather sporadic in Eastern Europe. Therefore, our goal was to determine the prevalence of childhood hypertension and its concomitant metabolic abnormalities using data mining methods.

Methods

We evaluated data from 3 to 18-year-old children who visited the University of Debrecen Clinical Center's hospital throughout a 15-year study period (n = 92,198; boys/girls: 48/52%).

Results

We identified a total of 3,687 children with hypertension (2,107 boys and 1,580 girls), with a 4% calculated prevalence of hypertension in the whole study population and a higher prevalence in boys (4.7%) as compared to girls (3.2%). Among boys we found an increasing prevalence in consecutive age groups in the study population, but among girls the highest prevalences are identified in the 12-15-year age group. Markedly higher BMI values were found in hypertensive children as compared to non-hypertensives in all age groups. Moreover, significantly higher total cholesterol (4.27 ± 0.95 vs. 4.17 ± 0.88 mmol/L), LDL-C (2.62 ± 0.79 vs. 2.44 ± 0.74 mmol/L) and triglyceride (1.2 (0.85-1.69) vs. 0.94 (0.7-1.33) mmol/L), and lower HDL-C (1.2 ± 0.3 vs. 1.42 ± 0.39 mmol/L) levels were found in hypertensive children. Furthermore, significantly higher serum uric acid levels were found in children with hypertension (299.2 ± 86.1 vs. 259.9 ± 73.3 μmol/L), while glucose levels did not differ significantly.

Conclusion

Our data suggest that the calculated prevalence of childhood hypertension in our region is comparable to data from other European countries and is associated with early metabolic disturbances. Data mining is an effective method for identifying childhood hypertension and its metabolic consequences.

Persistent high blood pressure and renal dysfunction in preterm infants during childhood

BACKGROUND

Infants born very preterm (≤32 weeks gestational age, GA) and very-low birth weight (≤1500 g; PT-VLBW) demonstrate high systolic blood pressure (SBP), renal dysfunction, and obesity at 6 months-3 years and in early adulthood. Their parallel measurement and progression during childhood is unclear.

METHODS

We reenrolled 62/120 patients originally seen at 1-3 years at 10-13 years and remeasured anthropometric indices, SBP, and serum creatinine (Cr) and cystatin C (cysC) to determine estimated glomerular filtration rate (eGFR). We selected Term-matched Controls at 10-13 years from the 2015-2016 NHANES database at a ratio of 2 Controls:1 Case (124:62).

RESULTS

Reenrolled patients were predominantly Hispanic, birth weight 1073 ± 251 g, and GA at birth 28 ± 2 weeks. At 10-13 years, 45% were classified overweight/obese, 48% had SBP ≥ 90th centile (77% considered hypertensive), and 34% had low eGFR (<90 mL min^-1 [1.73 m²]^-1). Notably, 57% of reenrolled PT-VLBW Cases had low eGFR_cysC at both 1-3 and 10-13 years, P < 0.03. Compared to Controls, Cases had four times the adjusted odds for having an elevated SBP and low eGFR_Cr despite similar proportions with overweight/obesity among Cases and Controls.

CONCLUSIONS

PT-VLBW infants seen at 1-3 years exhibit obesity, elevated SBP, and low eGFR in infancy and 10-13 years. Although the small sample size may limit conclusions, pediatricians should consider serial evaluations of PT-VLBW throughout childhood.

IMPACT

The association between preterm birth and elevated blood pressure, renal dysfunction, and obesity in young adults begins as early as 1 year and persists at 10-13 years of age. This is the first study reporting serial measurements of blood pressure, renal function, and obesity from infancy to preadolescence in children born very preterm. Fifty-seven percent of preterm 1-3 year olds have persistent low estimated glomerular filtration rate associated with hypertension at 10-13 years. Clinicians should consider serial evaluations of blood pressure, renal function, and obesity throughout infancy and childhood in all preterm births.

Reliability of Self-Reported Height and Weight in Children: A School-Based Cross-Sectional Study and a Review

Since anthropometric measurements are not always feasible in large surveys, self-reported values are an alternative. Our objective was to assess the reliability of self-reported weight and height values compared to measured values in children with (1) a cross-sectional study in Switzerland and (2) a comprehensive review with a meta-analysis. We conducted a secondary analysis of data from a school-based study in Switzerland of 2616 children and a review of 63 published studies including 122,629 children. In the cross-sectional study, self-reported and measured values were highly correlated (weight: r = 0.96; height: r = 0.92; body mass index (BMI) r = 0.88), although self-reported values tended to underestimate measured values (weight: -1.4 kg; height: -0.9 cm; BMI: -0.4 kg/m2). Prevalence of underweight was overestimated and prevalence of overweight was underestimated using self-reported values. In the meta-analysis, high correlations were found between self-reported and measured values (weight: r = 0.94; height: r = 0.87; BMI: r = 0.88). Weight (-1.4 kg) and BMI (-0.7 kg/m2) were underestimated, and height was slightly overestimated (+0.1 cm) with self-reported values. Self-reported values tended to be more reliable in children above 11 years old. Self-reported weight and height in children can be a reliable alternative to measurements, but should be used with caution to estimate over- or underweight prevalence.

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.

Pediatric obesity-Long-term consequences and effect of weight loss

Childhood obesity is, according to the WHO, one of the most serious challenges of the 21st century. More than 100 million children have obesity today. Already during childhood, almost all organs are at risk of being affected by obesity. In this review, we present the current knowledge about diseases associated with childhood obesity and how they are affected by weight loss. One major causative factor is obesity-induced low-grade chronic inflammation, which can be observed already in preschool children. This inflammation-together with endocrine, paracrine, and metabolic effects of obesity-increases the long-term risk for several severe diseases. Type 2 diabetes is increasingly prevalent in adolescents and young adults who have had obesity during childhood. When it is diagnosed in young individuals, the morbidity and mortality rate is higher than when it occurs later in life, and more dangerous than type 1 diabetes. Childhood obesity also increases the risk for several autoimmune diseases such as multiple sclerosis, Crohn's disease, arthritis, and type 1 diabetes and it is well established that childhood obesity also increases the risk for cardiovascular disease. Consequently, childhood obesity increases the risk for premature mortality, and the mortality rate is three times higher already before 30 years of age compared with the normal population. The risks associated with childhood obesity are modified by weight loss. However, the risk reduction is affected by the age at which weight loss occurs. In general, early weight loss-that is, before puberty-is more beneficial, but there are marked disease-specific differences.

Pharmacological Treatment of Arterial Hypertension in Children and Adolescents in Lithuania

The global prevalence of arterial hypertension (AH) in the pediatric population is increasing, but therapeutic approaches and the choice of the most suitable antihypertensive medications remains challenging. The study aimed to estimate the prevalence, treatment rates, and pharmacological treatment patterns of children and adolescents with AH in Lithuania during 2019 using real-world data. The study population consisted of citizens of Lithuania aged 0 to 17 years, who were diagnosed with AH according to the International Classification of Diseases (ICD). The analysis of reimbursed antihypertensive medication prescriptions was performed according to AH etiology and age. The overall prevalence of AH by diagnostic ICD codes in 2019 was 0.29%:0.24% for primary and 0.05% for secondary. Treatment rates were 39.8% for primary AH and 66.3% for secondary AH. Angiotensin-converting enzyme inhibitors (ACEi) were the most popular medications irrespective of the etiology of AH or age. Beta-blockers were in the second place and used more often in older children. Calcium channel blockers were the third and angiotensin receptor blockers were the fourth most frequent choices. Enalapril was the most popular agent in the ACEi group and metoprolol in the beta-blocker group. Nearly forty percent of Lithuanian children with primary AH receive pharmacological therapy compared to two-thirds with secondary AH. Although ACEi are the predominant class of antihypertensive medications, discordances with available guidelines are evident, particularly in the overuse of beta-blockers and underuse of diuretics.

Isolated systolic hypertension in the young: a heterogeneous condition

Isolated systolic hypertension in the youth, is still a challenging problem. The prevalence of this hypertensive subtype may vary according to the different population study and is peculiar of male subjects among the youngest age classes. Several are the mechanisms reported as possible underlying causes of isolated systolic blood pressure elevation and again these differ according to the different study cohort and may vary from overweight and obesity status, linked to sympathetic overactivity, to increased and earlier arterial stiffness, hyperkinetic state, or exaggerated pulse pressure amplification form central to peripheral sites, due to enhanced arterial elasticity. Evidence is lacking regarding whether this condition is benign or associated to unfavorable cardiovascular events. The few long-term studies that followed isolated systolic hypertensives in the long-term, again reported conflicting results. Waiting for future studies, some clinical and hemodynamic characteristics of young isolated systolic hypertensives may help clinicians to better characterized patient's risk profile and decide whether to perform a strict follow-up with non-pharmacological measurements or to start drug treatment.

Body surface area-based kidney length percentiles misdiagnose small kidneys in children with overweight/obesity

BACKGROUND

We evaluated the diagnostic performance of height-, age- and body surface area (BSA)-based kidney length (KL) percentiles in the identification of at least one small kidney (KL < 3^rd) and in the prediction of reduced estimated glomerular filtration rate (eGFR) and/or elevated blood pressure (BP) in children with and without overweight (OW)/obesity(OB).

METHODS

In this cross-sectional study, 744 apparently healthy children (mean age 8.3 years) were recruited in a primary care setting. Clinical data were collected, and serum creatinine and KL were measured. Height-, age- and BSA-based percentiles of KL were calculated and the association of at least one small kidney per subject with reduced eGFR and/or elevated BP was explored by logistic regression.

RESULTS

Two hundred fifty-seven out of seven hundred forty-four (34.5%) subjects were OW/OB and 127 (17.1%) had reduced eGFR or elevated BP. In separate analyses in children with OW/OB, the KL percentiles calculated on the basis of BSA were lower compared with height- and age-based KL percentiles. Consequently, the prevalence of a small kidney was significantly higher when evaluating percentiles of KL based on BSA compared with other percentiles. In logistic regression analysis, a small kidney was significantly associated with reduced eGFR and/or elevated BP only when using height-based KL percentiles. The KL percentiles according to BSA for the ideal weight (iBSA) showed similar performance compared with height-based percentiles. No differences in the diagnostic performance of different percentiles were found in children with normal weight.

CONCLUSIONS

BSA-based percentiles underestimate KL in children with OW/OB. In these subjects, the use of height-based or iBSA-based percentiles should be preferred. A higher resolution version of the Graphical abstract is available as Supplementary information.

Effects of ambulatory blood pressure monitoring parameters on left ventricular mass index in hypertensive children

OBJECTIVE

We aimed to evaluate the effects of blood pressure (BP) values obtained by 24-h ambulatory BP monitoring (ABPM) of hypertensive children and adolescents on left ventricular mass index (LVMI).

METHODS

Patients diagnosed with HT with BP measurements confirmed with ABPM and evaluated with echocardiography for LVMI were included. The patients were divided into two groups according to their BMI as obese and nonobese. SDSs of ABPM parameters were compared between the groups.

RESULTS

A total of 158 children with HT were included in the study. Ninety of these patients were obese. In obese and nonobese cases, mean SDS levels were similar in ABPM parameters, whereas LVMI was significantly higher in obese patients ( P = 0.049). There was a significant correlation between LVMI and 24-h SBP SDS, daytime SBP SDS, 24-h SBP load and daytime BP load. In obese cases, there was a statistically significant correlation between LVMI and 24-h SBP SDS, daytime SBP SDS, 24-h SBP load, daytime SBP load as well as nighttime SBP SDS and nighttime SBP load. When the whole group was evaluated, 24-h SBP SDS was the most effective parameter influencing LVMI ( P = 0.001). Similarly, the most effective ABPM parameter on LVMI in obese patients was 24-h SBP SDS ( P = 0.001).

CONCLUSION

A significantly higher rate of LVMI in obese patients suggests that obesity itself is an effective factor on LVMI. In addition, systolic hypertension is more effective on cardiac functions compared with DBP measurements and systolic-DBP dipping ratios.

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.

Development and Validation of a Nomogram-Based Prognostic Model to Predict High Blood Pressure in Children and Adolescents—Findings From 342,736 Individuals in China

Objectives

Predicting the potential risk factors of high blood pressure (HBP) among children and adolescents is still a knowledge gap. Our study aimed to establish and validate a nomogram-based model for identifying youths at risk of developing HBP.

Methods

HBP was defined as systolic blood pressure or diastolic blood pressure above the 95th percentile, using age, gender, and height-specific cut-off points. Penalized regression with Lasso was used to identify the strongest predictors of HBP. Internal validation was conducted by a 5-fold cross-validation and bootstrapping approach. The predictive variables and the advanced nomogram plot were identified by conducting univariate and multivariate logistic regression analyses. A nomogram was constructed by a training group comprised of 239,546 (69.9%) participants and subsequently validated by an external group with 103,190 (30.1%) participants.

Results

Of 342,736 children and adolescents, 55,480 (16.2%) youths were identified with HBP with mean age 11.51 ± 1.45 years and 183,487 were boys (53.5%). Nine significant relevant predictors were identified including: age, gender, weight status, birth weight, breastfeeding, gestational hypertension, family history of obesity and hypertension, and physical activity. Acceptable discrimination [area under the receiver operating characteristic curve (AUC): 0.742 (development group), 0.740 (validation group)] and good calibration (Hosmer and Lemeshow statistics, P > 0.05) were observed in our models. An available web-based nomogram was built online on https://hbpnomogram.shinyapps.io/Dyn_Nomo_HBP/.

Conclusions

This model composed of age, gender, early life factors, family history of the disease, and lifestyle factors may predict the risk of HBP among youths, which has developed a promising nomogram that may aid in more accurately identifying HBP among youths in primary care.

Body Composition and Cardiovascular Risk Factors in a Paediatric Population

The aim of our study was to evaluate associations between body composition parameters and several clinical parameters. A total of 206 children and adolescents (120 male, 86 female) were prospectively included. Body impedance measurement was performed in all participants. During the hospital work-up, several clinical parameters such as anthropometric measurements and laboratory and ultrasound findings were obtained and correlated to body composition parameters. There was a significant association between body composition parameters and anthropometric measurements, systolic blood pressure, insulin levels, serum creatinine, urate, liver function tests, triglycerides, cholesterols and apolipoproteins, homocysteine, vitamin D and proteins in 24-h urine. Body composition differed by gender, between participants with and without hepatic steatosis and between patients with and without left ventricular hypertrophy. Interestingly, body composition did not correlate with diastolic blood pressure, pulse wave velocity and intima media thickness. This study showed that several clinical parameters are associated with body composition in children. Obesity and body composition play an important role in the development of other cardiovascular risk factors and are not dependent on fat mass alone, and the latter might be used for cardiovascular risk determination.

Blood pressure profile, prevalence of hypertension and associated familial factors in school children in Accra, Ghana

Background

Essential hypertension, which is hypertension without a known cause, runs in families. Children from families with hypertension are likely to have a higher blood pressure than children from normotensive families.

Aim

The aim of this study was to find the prevalence of hypertension and the associated family risk factors for hypertension in the school children.

Patients and Methods

This prevalence study was conducted in six first-cycle schools in Accra, Ghana. School children between the ages of five to fourteen years were recruited into the study. A questionnaire, which gathered information on demographic data, family history, and risk factors associated with childhood hypertension and the child's clinical data, was used. An average of three blood pressure readings with an automated sphygmomanometer and height measurement was taken for each child. Blood pressure was categorized as normal, pre-hypertension, and hypertension using the Centers for Disease Control and Prevention (CDC) reference charts.

Results

A total of 600 school children comprising 358 (59.7%) females and 242 (40.3%) males were studied. Fifty-one (8.5%) school children had elevated blood pressure. Of these, 15 (2.5%) had hypertension, while 36 (6.0%) had pre-hypertension. Two hundred and thirty-eight participants had a family history of risk factors for hypertension. Twenty-five (10.5%) children with risk factors (family history of hypertension, diabetes mellitus, obesity, stroke) had elevated blood pressure (BP) compared to 7.2% of those without risk factors.

Conclusion

Urgent positive lifestyle transformations, which should start from school to reduce the incidence of hypertension in children.

Prevalence Implications of the 2017 American Academy of Pediatrics Hypertension Guideline and Associations with Adult Hypertension

OBJECTIVE

To evaluate the impact of the 2017 American Academy of Pediatrics hypertension Clinical Practice Guideline (CPG), compared with the previous guideline ("Fourth Report"), on the frequency of hypertensive blood pressure (BP) measurements in childhood and associations with hypertension in adulthood using data from the International Childhood Cardiovascular Cohort Consortium.

STUDY DESIGN

Childhood BPs were categorized in normal, prehypertensive/elevated, and hypertensive (stage 1 and 2) ranges using the Fourth Report and the CPG. Participants were contacted in adulthood to assess self-reported hypertension. The associations between childhood hypertensive range BPs and self-reported adult hypertension were evaluated.

RESULTS

Data were available for 34 014 youth (10.4 ± 3.1 years, 50.6% female) with 92 751 BP assessments. Compared with the Fourth Report, the CPG increased hypertensive readings from 7.6% to 13.5% and from 1.3% to 2.5% for stage 1 and 2 hypertensive range, respectively (P < .0001). Of 12 761 adults (48.8 ± 7.9 years, 43% male), 3839 (30.1%) had self-reported hypertension. The sensitivity for predicting adult hypertension among those with hypertensive range BPs at any point in childhood, as defined by the Fourth Report and the CPG, respectively, was 13.4% and 22.4% (specificity 92.3% and 85.9%, P < .001), with no significant impact on positive and negative predictive values. Associations with self-reported adult hypertension were similar and weak (c-statistic range 0.61-0.68) for hypertensive range BPs as defined by the Fourth Report and CPG.

CONCLUSIONS

The CPG significantly increased the prevalence of childhood BPs in hypertensive ranges and improved the sensitivity, without an overall strengthened association, of predicting self-reported adult hypertension.

Risk of Higher Blood Pressure in 3 to 6 Years Old Singleton Born From OHSS Patients Undergone With Fresh IVF/ICSI

BACKGROUND

A large registry-based study found the increasing disorders of cardiovascular and metabolism in IVF children but underlying mechanism is still unknown. Few studies have investigated any association between OHSS and cardiovascular or metabolic function in subsequent children.

OBJECTIVE

To evaluate the effect of ovarian hyperstimulation syndrome (OHSS) on blood pressure of singletons after in vitro fertilization (IVF) with or without intracytoplasmic sperm injection (ICSI).

STUDY DESIGN

The singlet-center corhort study included 1780 singletons born with IVF/ICSI and 83 spontaneously conceived children from 2003 to 2014. Follow-up has lasted more than 10 years, and is still ongoing. This study analyzed data from follow-up surveys at 3 to 6 years of age.

PARTICIPANTS SETTING AND METHODS

We recruited 83 children (Group E) spontaneously conceived (SC) as control group and 1780 children born with IVF/ICSI including 126 children born to OHSS-fresh embryo transfer (ET) women (Group A), 1069 children born to non OHSS-ET women (Group B), 98 children conceived by women who developed into moderate or severe OHSS after oocyte retrieval and selected the frozen-thawed embryo transfer (FET) (Group C), 487 children conceived with non OHSS-FET (Group D). We evaluated cardiometabolic function, assessed BP in mmHg, heart rate, anthropometrics, and metabolic index including glucose, serum lipid (triglyceride, total cholesterol, low density lipoprotein, high density lipoprotein), thyroid function, of those children. The BP and heart rate were measured twice on the same day. We applied several multiple regression analyses to investigate the effect of OHSS in the early pregnancy.

MAIN FINDINGS

By the single factor analysis, the SBP and DBP in the SC group (SBP: 99.84 ± 8.9; DBP: 55.27 ± 8.8) were significantly lower than OHSS-ET group's, while the blood pressure was similar between the SC group and other three ART groups. Children had higher BP in the OHSS-ET group (SBP: 101.93 ± 8.17; DBP: 58.75 ± 8.48) than in the non OHSS-ET (SBP: 99.49 ± 8.91; DBP: 56.55 ± 8.02) or OHSS-FET group (SBP: 99.38 ± 8.17; DBP: 55.72 ± 7.94). After using multiple regression analysis to adjust current, early life, parental and ART characteristics, the differences in the SBP and DBP (B (95% confidence interval)) between OHSS-ET and non OHSS-ET remained significant (SBP: 3.193 (0.549 to 2.301); DBP: 3.440 (0.611 to 2.333)). And the BP showed no significant difference complementarily when compared non OHSS-FET group with non OHSS-ET group. In addition, the anthropometrics, fast glucose, serum lipid, and thyroid index did not differ among the ART groups.

PRINCIPAL CONCLUSIONS

OHSS might play an independent key role on offspring's BP even cardiovascular function. Electing frozen-thawed embryo transfer for high risk of OHSS population may reduce the risk of the high BP trend.

WIDER IMPLICATIONS OF THE FINDINGS

It is a large sample study to investigate the effect of OHSS on offspring's health. These findings provide a clinic evidence of the impact of early environment (embryo even oocyte stage) on the offspring's cardiovascular health. Our study emphasis the importance of the accuracy of IVF clinic strategy and preventing the OHSS after fresh embryo transfer.

A demographic approach to assess elevated blood pressure and obesity in prepubescent children: the ExAMIN Youth South Africa study

BACKGROUND

Obesity and hypertension prevalence among children are a concern, with limited evidence available on sex and ethnic differences in childhood blood pressure. We aimed to determine the number of children with hypertension and obesity to identify unique adiposity and blood pressure characteristics by sex and ethnicity, and to estimate the odds of having elevated blood pressure with increasing adiposity.

METHODS

We included 1062 healthy children (5-9 years of age) in an observational school-based study in South Africa. Pediatric validated automated devices were used to measure brachial blood pressure and performed pulse wave analysis to assess central hemodynamics. Standard anthropometry was carried out to determine body composition and demographic questionnaires were completed.

RESULTS

Almost 20% of children were overweight/obese and 14.1% had elevated blood pressure or hypertension (22.8%). Ethnic differences included greater adiposity in white compared with black children (all P < 0.0001), but higher DBP and total vascular resistance in black compared with white children (both P < 0.05). DBP and total vascular resistance were also higher in girls than boys (both P < 0.01). A 51-60% increased risk of developing elevated blood pressure was observed for 1SD (standard deviation) increase of sex-specific BMI [1.60 (1.4-1.8); P < 0.0001] and waist/height ratio [1.51 (1.3-1.7); P < 0.0001].

CONCLUSION

Unique sex and ethnic differences in body composition and blood pressure exist in prepubescent children, with overweight/obesity increasing the risk of elevated blood pressure. Our findings support primary prevention strategies to combat the growing burden of hypertension and obesity-related diseases in youth.

TRIAL REGISTRATION

The study is registered on ClinicalTrials.gov (NCT04056377).

How Does Being Overweight Moderate Associations between Diet and Blood Pressure in Male Adolescents?

Diet is one of the strongest modifiable risk factors for hypertension. In this study, we described the associations between dietary factors and blood pressure; and explored how weight status moderated these associations in a sample of New Zealand male adolescents. We collected demographics information, anthropometric, blood pressure, and dietary data from 108 male adolescents (15–17 years old). Mixed effects and logistic regression models were used to estimate relationships between dietary variables, blood pressure, and hypertension. Moderation effects of overweight status on the relationship between hypertension and diet were explored through forest plots. One-third (36%) of the sample was classified as hypertensive. Fruit intake was related to significantly lower systolic (−2.4 mmHg, p = 0.005) and diastolic blood pressure (−3.9 mmHg, p = 0.001). Vegetable and milk intake was related to significantly lower diastolic blood pressure (−1.4 mmHg, p = 0.047) and (−2.2 mmHg, p = 0.003), respectively. In overweight participants, greater vegetable and milk, and lower meat intake appeared to reduce the odds of hypertension. Certain dietary factors may have more prominent effects on blood pressure depending on weight status.

Trends in Prevalence of Hypertension and Hypertension Phenotypes Among Chinese Children and Adolescents Over Two Decades (1991-2015)

Background: Hypertension is a leading cause of cardiovascular-related morbidity and mortality. Elevated blood pressure (BP) in children is related to long-term adverse health effects. Until recently, few studies have reported the secular trend and associated factors of hypertension phenotypes in Chinese children and adolescents. Methods: From the China Health and Nutrition Survey (CHNS) 1991-2015, a total of 15,143 records of children aged 7-17 years old were included. Following definitions of hypertension from the Chinese Child Blood Pressure References Collaborative Group, we estimated the prevalence of prehypertension, hypertension, stage 1 hypertension, stage 2 hypertension and its phenotypes (ISH, isolated systolic hypertension; IDH, isolated diastolic hypertension; SDH, combined systolic and diastolic hypertension). General estimation equation was used to analyze the trends in the prevalence of hypertension and hypertension phenotypes, and a multivariable logistic regression was constructed to explore the associated factors. Results: During 1991-2015, increasing trends were revealed in BP and hypertension prevalence (P < 0.001) in Chinese children and adolescents. For ISH, IDH and SDH, the age-standardized prevalence increased dramatically from 0.9 to 2.2%, from 6.2 to 14.1%, and from 1.4 to 2.9%, respectively (all P < 0.001). Adolescents aged 13-17 years (OR = 1.76, 95% CI: 1.56-1.97, P < 0.001), general obesity (OR = 2.69, 95% CI: 2.10-3.44, P < 0.001) and central obesity (OR = 1.49, 95% CI: 1.21-1.83, P < 0.001) were positively associated with hypertension, whereas the South region (OR = 0.65, 95% CI: 0.58-0.73, P < 0.001) was a negative factor. Furthermore, body mass index (BMI) and general obesity were linked to the presence of ISH, IDH and SDH. Age, waist circumference (WC) and central obesity were additionally associated with ISH, and sex, age, urban/rural setting, North/South region, WC and central obesity were additionally associated with IDH. Conclusion: BP levels and prevalence of hypertension and phenotypes increased dramatically in Chinese children and adolescents from 1991 to 2015. Regional discrepancy, demographic features, BMI, WC and overweight/obesity status were associated factors of hypertension among youths.

Factors Associated with Primary Hypertension in Pediatric Patients: An Up-to-Date

BACKGROUND

Arterial hypertension in children is considered a common alteration nowadays, mainly because obesity is a growing worldwide problem closely related to increased blood pressure. Childhood hypertension can be classified as primary or secondary, depending on the etiology. Primary or essential hypertension still has its pathophysiology not fully elucidated, and there is no consensus in the literature on most underlying mechanisms. In this review, genetic and environmental factors, including sodium and potassium intake, socioeconomic status, ethnicity, family structure, obesity, sedentary lifestyle, prematurity and low birth weight, prenatal and postnatal exposures are highlighted.

OBJECTIVE

The present study aimed to perform an update on primary hypertension in childhood, providing clinicians and researchers an overview of the current state of the literature regarding the influence of genetic and environmental factors.

METHODS

This integrative review searched for articles on genetic and environmental factors related to primary hypertension in pediatric patients. The databases evaluated were PubMed and Scopus.

RESULTS

The studies have provided insights regarding many genetic and environmental factors, in addition to their association with the pathophysiology of primary hypertension in childhood. Findings corroborated the idea that primary hypertension is a multifactorial disease. Further studies in the pediatric population are needed to elucidate the underlying mechanisms.

CONCLUSION

The study of primary hypertension in pediatrics has utmost importance for the adoption of preventive measures and the development of more efficient treatments, therefore reducing childhood morbidity and the incidence of cardiovascular diseases and other health consequences later in life.

Hypertension in Children and Adolescents: A Position Statement From a Panel of Multidisciplinary Experts Coordinated by the French Society of Hypertension

Hypertension is much less common in children than in adults. The group of experts decided to perform a review of the literature to draw up a position statement that could be used in everyday practice. The group rated recommendations using the GRADE approach. All children over the age of 3 years should have their blood pressure measured annually. Due to the lack of data on cardiovascular morbidity and mortality associated with blood pressure values, the definition of hypertension in children is a statistical value based on the normal distribution of blood pressure in the paediatric population, and children and adolescents are considered as having hypertension when their blood pressure is greater than or equal to the 95th percentile. Nevertheless, it is recommended to use normative blood pressure tables developed according to age, height and gender, to define hypertension. Measuring blood pressure in children can be technically challenging and several measurement methods are listed here. Regardless of the age of the child, it is recommended to carefully check for a secondary cause of hypertension as in 2/3 of cases it has a renal or cardiac origin. The care pathway and principles of the therapeutic strategy are described here.

ANTHROPOMETRIC MEASUREMENTS, DIETARY HABITS, SERUM LIPID AND GLUCOSE LEVELS IN RELATION TO HIGH BLOOD PRESSURE AMONG ADOLESCENT BOYS AND GIRLS IN CROATIA

The aim was to determine differences in anthropometric measurements, dietary habits, serum lipid and glucose levels in relation to high blood pressure (BP) among adolescent boys and girls in Croatia. The specific aim was to determine the effect of dietary habits and lifestyle on high BP in adolescents according to sex. The study included 260 (68.2%) adolescent girls and 121 (31.8%) boys with anthropometric data obtained (without missing values) from 246 girls and 111 boys. Participants answered questions from the questionnaire and anthropometric BP and blood test values were obtained. Non-parametric tests were used in analyses of reference intervals of systolic and diastolic BP in adolescent boys and girls according to age. High BP was defined as ≥90^th percentile for adolescent girls and boys, with a value of ≥135/87.5 mm Hg. Mann-Whitney U test was used to analyze differences in anthropometric and laboratory values between the groups of girls and boys with high (≤90^th percentile) and normal BP. Increase in systolic and diastolic BP was noted in the adolescents. In girls, BP values showed a decreasing systolic and increasing diastolic BP trend with age. Girls with high BP had a significantly higher body mass index (BMI) (p=0.020), waist circumference (WC) (p=0.002), waist-to-height ratio (WHtR) (p=0.016), waist-to-hip ratio (WHR) (p=0.043), hip circumference (HC) (p=0.015), triglyceride (TG) levels (p=0.021), higher prevalence of unhealthy diet at school breakfast (p=0.008) and lower prevalence of eating fish (p=0.02). Boys with high BP had a significantly higher BMI (p=0.045), WC (p=0.004), WHtR (p=0.017), WHR (p=0.022) and higher prevalence of eating meat products (p=0.015). Effective health interventions are needed to reduce the risk of developing cardiovascular diseases and preventing age-related illness.

Prevalence and factors that are associated with elevated blood pressure among primary school children in Mwanza Region, Tanzania

Introduction

hypertension (HTN) among children is reported to be increasing due to sedentary lifestyles. In developed countries the prevalence of paediatric HTN is recorded to be up to 21% while the magnitude of the same is up to 11% in Tanzania. This study aimed to determine the blood pressure profile and factors associated with elevated blood pressure (BP) among children of Mwanza region.

Methods

a cross sectional study involving 742 children aged 6 to 16 years in selected primary schools in Mwanza region was conducted from June to August 2019. Data were collected using self-administered structured questionnaires where parents helped children to fill in. Blood pressure, body weight and height were measured using digital portable sphygmomanometer, self-calibrating digital weighing scale and Shorr measuring board respectively. Data were analyzed using EpiInfo.

Results

this study found mean systolic blood pressure (SBP) and diastolic blood pressure (DBP) were 109.2 ± 8.1 mmHg and 62.3 ± 7.2 mmHg respectively. Prevalence of elevated BP was 18.1%. Pre-hypertension 9.6%, and hypertension 8.5%. The age specific elevated BP prevalence was significantly higher (OR = 1.9, 95% CI: 1.2 - 2.9, p = 0.008) among children aged ≥10 years (21.4%) than younger ones (15.1%). Prevalence was also higher (OR = 1.5, 95% CI: 1.1 - 2.3, p = 0.048) among girls (20.1%) than boys (16.0%). Elevated BP was found to be associated with obesity (OR = 3.5, 95% CI: 1.6 - 7.7, p = <0.001), overweight (OR = 1.9, 95% CI: 1.1 - 3.3, p = 0.037), eating fried food (OR = 2.2, 95% CI: 1.1 - 4.4, p = 0.023), drinking sugar soft drinks (OR = 2.0, 95% CI: 1.2 - 3.5, p = 0.002) and not eating fruits (OR = 13.4, 1.6, 95% CI: 2.1 - 65.8, p-value 0.006).

Conclusion

findings indicate high prevalence of elevated BP among children of Mwanza region. There was an association between elevated BP and increased age, gender, sedentary lifestyle and obesity. Importance of measuring paediatric blood pressure and health information regarding effects of sedentary life is recommended to Tanzanians. Parents should encourage their children to have active physical activities. Moreover, health workers should implement programmes to modify sedentary lifestyle and prevent children from elevated blood pressure.

Body Mass Index and Blood Pressure-to-Height Ratio in Predicting Incidence of Hypertension in Serbian Children

BACKGROUND

A new method using blood pressure-to-height ratio for diagnosing elevated blood pressure/hypertension in children has been introduced recently. We aimed to compare blood pressure-to-height ratio (BPHR) and Body Mass Index (BMI) in predicting incidence of hypertension (HTN).

METHODS

The sample consisted of 1133 boys and 1154 girls aged 7-15. We used the following equations for BPHR: systolic BPHR (SBPHR) = SBP (mm Hg)/height (cm) and diastolic BPHR (DBPHR) = DBP (mm Hg)/height (cm). In order to determine the accuracy of SBPHR, DBPHR and BMI as diagnostic tests for elevated blood pressure (elevated BP), we used the receiveroperating characteristic curve analyses.

RESULTS

The area under the curve (AUC) values for BMI ranged from 0.625 to 0.723 with quite low sensitivity rates from 62% to 72.5% and specificities from 58.2% to 67.3% showing a modest ability to identify children with elevated BP and HTN. On the contrary, BPHR showed a great predictive ability to identify elevated BP and HTN with AUC values of 0.836 to 0.949 for SBP and from 0.777 to 0.904 for DBP. Furthermore, the sensitivity ranged from 78.5% to 95.7%, and the specificity from 73.9% to 87.6%.

CONCLUSION

the current study showed that BPHR is an accurate index for detecting elevated BP and HTN in children aged 7 to 15 years and can be used for early screening.

Dietary Approaches to Stop Hypertension Dietary Intervention Improves Blood Pressure and Vascular Health in Youth With Elevated Blood Pressure

This randomized control trial assessed the post-intervention and 18-month follow-up effects of a 6-month dietary approaches to stop hypertension (DASH)-focused behavioral nutrition intervention, initiated in clinic with subsequent telephone and mail contact, on blood pressure (BP) and endothelial function in adolescents with elevated BP. Adolescents (n=159) 11 to 18 years of age with newly diagnosed elevated BP or stage 1 hypertension treated at a hospital-based clinic were randomized. DASH participants received a take-home manual plus 2 face-to-face counseling sessions at baseline and 3 months with a dietitian regarding the DASH diet, 6 monthly mailings, and 8 weekly and then 7 biweekly telephone calls focused on behavioral strategies to promote DASH adherence. Routine care participants received nutrition counseling with a dietitian consistent with pediatric guidelines established by the National High Blood Pressure Education Program. Outcomes, measured pre- and post-intervention and at 18-months follow-up, included change in BP, change in brachial artery flow-mediated dilation, and change in DASH score based on 3-day diet recalls. Adolescents in DASH versus routine care had a greater improvement in systolic BP (-2.7 mm Hg, P= 0.03, -0.3 z-score, P=0.03), flow-mediated dilation (2.5%, P=0.05), and DASH score (13.3 points, P<0.0001) from baseline to post-treatment and a greater improvement in flow-mediated dilation (3.1%, P=0.03) and DASH score (7.4 points, P=0.01) to 18 months. The DASH intervention proved more effective than routine care in initial systolic BP improvement and longer term improvement in endothelial function and diet quality in adolescents with elevated BP and hypertension. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT00585832.

Haemodynamics of Hypertension in Children

PURPOSE OF REVIEW

To review the haemodynamic characteristics of paediatric hypertension.

RECENT FINDINGS

Pulsatile components of blood pressure are determined by left ventricular dynamics, aortic stiffness, systemic vascular resistance and wave propagation phenomena. Recent studies delineating these factors have identified haemodynamic mechanisms contributing to primary hypertension in children. Studies to date suggest a role of cardiac over activity, characterized by increased heart rate and left ventricular ejection, and increased aortic stiffness as the main haemodynamic determinants of primary hypertension in children.

The Get-Up! study: adiposity and blood pressure in Australian toddlers

BACKGROUND

Because the elevated blood pressure (BP) in childhood is strongly associated with overweight and is a risk factor for later cardiovascular disease, a need to comprehend the early development of BP and its association with overweight is needed. We assessed differences of BP by weight status in Australian toddlers.

METHODS

From the Get-Up! Study in Australia, this sample included 265 toddlers (136 boys), aged 19.6 ± 4.2 months. BP was measured with a digital vital signs monitor. Participants were categorized as nonoverweight and overweight according to the World Health Organization definition for body mass index (BMI). Physical activity was captured with activPAL accelerometers, during childcare hours. To test differences in BP between nonoverweight and overweight children, we performed an analysis of covariance adjusting for sex, age, physical activity, and socioeconomic status.

RESULTS

Children with overweight showed higher z systolic BP values (P = .042 for BMI and P = .023 for waist circumference) when compared to nonoverweight children. However, no differences were found for z diastolic BP levels, between overweight and nonoverweight children. After adjustments for potential confounders (socioeconomic status, physical activity, sex, and age), there were no significant differences in BP variables between BMI and waist circumference groups.

CONCLUSIONS

No associations between adiposity and BP levels were found in this sample. The unadjusted results, however, showed that children with higher levels of adiposity (BMI and waist circumference) exhibited higher levels of BP. Additional research is needed to determine which environmental and genetic factors might contribute to pediatric hypertension, particularly among toddlers.

Optimizing the implementation of a population panel management intervention in safety-net clinics for pediatric hypertension (The OpTIMISe-Pediatric Hypertension Study)

BACKGROUND

Though clinical practice guidelines are available, the diagnosis of pediatric hypertension (HTN) is often missed. Management may not follow guidelines due to the measurement challenges in children, complexity of interpreting youth blood pressure standards that are dependent on height, age, and sex, familiarity with diagnostic criteria, and variable comfort with management of pediatric HTN among providers. Evidence suggests that wide adoption and adherence to pediatric HTN guidelines would result in lower cardiovascular disease and kidney damage in adulthood. The proposed project will develop an implementation strategy package to increase adherence to clinical practice guidelines for pediatric HTN within safety-net community health centers (CHCs). The centerpiece of which is a provider-facing population panel management (PPM) tool and point-of-care clinical decision support (CDS). Prior research indicates that multiple discrete implementation strategies (e.g., stakeholder involvement, readiness planning, training, ongoing audit and feedback) are needed to institute practice- and provider-level adoption of such tools.

METHODS

Using participatory research methods involving stakeholders from a practice-based research network of CHCs, with input from scientific advisors, the project aims to (1) employ user-centered design methods to tailor an existing CDS tool for use at the point of care and optimize cohort management with a PPM tool to support adherence to the latest pediatric HTN guidelines, and (2) use a stakeholder-driven method for selecting implementation strategies that support tool adoption and increase guideline-adherent physician behaviors. Multilevel process evaluation using surveys and key informant interview data will assess the acceptability, adoption, appropriateness, cost, and feasibility of the PPM tool and its multicomponent implementation strategy package. Usability testing will be conducted with the PPM tool to iteratively refine features and ensure proper functionality.

DISCUSSION

The proposed research has the potential to improve identification, diagnosis, and management of HTN in primary care settings for high-risk youth by assisting healthcare providers in implementing the American Academy of Pediatrics' 2017 guidelines using an EHR-integrated PPM tool with CDS. Should the strategy package for PPM tool adoption be successful for pediatric HTN, findings will be translatable to other settings and PPM of other chronic cardiovascular conditions affecting overall population health.

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.

Elevated blood pressure and its relationship with bodyweight and anthropometric measurements among 8-11-year-old Indonesian school children

Objective: Increased prevalence of elevated blood pressure in children and adolescents was associated with increased body weight and measures. Also, prevalence of elevated blood pressure varies between countries. This study is to investigate the prevalence of elevated blood pressure in Indonesian children and its relationship with bodyweight and anthropometric measures. Methods: This cross-sectional study involved 1010 elementary students aged 8 - 12 years (479 girls, 531 boys). The anthropometric measures and blood pressure were assessed. Elevated blood pressure (EBP) was determined if at the 90^th percentile or above for gender, age, and height. Independent t-test, Chi-square, Pearson correlation, and multivariate logistic regression were applied. Significance was determined at p<0.05. Results: Overall prevalence of EBP was 28.8% (35.9% in girls, 22.4% in boys). BMI, waist circumference (WC), waist to height ratio (WHtR), and abdominal skinfold had significant correlation with EBP. Elevated BP was higher in overweight and obesity than in normoweight (60.5% vs 39.5%, p=0.00). In girls, the OR of EBP for overweight and obesity were 2.33 (95% CI 1.40-3.87, p=0.03) and 3.44 (95% CI 1.98-5.99, p=0.00) whereas in boys were 4.26 (95% CI 2.20-8.28, p=0.00) and 8.82 (95% CI 5.10-15.38, p=0.00). Conclusions: Prevalence of EBP in Indonesian school children aged 8 - 11 years was higher and more prevalent in overweight/ obesity and in girls. Anthropometric measures were correlated with EBP.

Evidence to Support Universal Blood Pressure Screening in School-Based Clinical Settings

BACKGROUND

Most pediatric elevated blood pressure (BP) remains undiagnosed. The American Academy of Pediatrics states "there is limited evidence to support school-based measurement of children's BP." We explored the utility school-based BP screening.

METHODS

A cross-sectional sample of 4096 students ages 6 to 17 from Title 1 Miami-Dade Public Schools (50% female, 71% non-Hispanic black, 26% Hispanic) had their systolic/diastolic BP (SBP/DBP) and body mass index (BMI) collected over the 2016 to 2017 or 2017 to 2018 school years. Relative risks (RRs) ratios were calculated to estimate normal/elevated SBP/DBP by BMI percentile, ethnicity, and sex.

RESULTS

Overall, 26.4% had at least one elevated BP measurement, of which 59% were not obese. RR for obese status was significant for all categories of elevated BP (RRs > 1.88, p < .0001). Being either female (RR = 1.34, p = .009) or Hispanic (RR = 1.31, p = .014) was significantly associated with elevated DBP. BMI accounted for <10% of the variation in BP (SBP: F(1, 4095) = 367.6, adjusted R²  = .08, p < .0001; DBP: F(1, 4095) = 93.3, adjusted R²  = .02, p < .0001).

CONCLUSION

These findings support providing BP screenings in school settings. Low-income and minority students often have limited access to health care, higher obesity rates, and unhealthy behaviors. Our findings support universal school-based BP screening regardless of weight status, particularly among ethnically diverse populations.

Prevention and Management of Childhood Obesity and Its Psychological and Health Comorbidities

Childhood obesity has become a global pandemic in developed countries, leading to a host of medical conditions that contribute to increased morbidity and premature death. The causes of obesity in childhood and adolescence are complex and multifaceted, presenting researchers and clinicians with myriad challenges in preventing and managing the problem. This article reviews the state of the science for understanding the etiology of childhood obesity, the preventive interventions and treatment options for overweight and obesity, and the medical complications and co-occurring psychological conditions that result from excess adiposity, such as hypertension, nonalcoholic fatty liver disease, and depression. Interventions across the developmental span, varying risk levels, and service contexts (e.g.,community, school, home, health care systems) are reviewed. Future directions for research are offered with an emphasis on translational issues for taking evidence-based interventions to scale in a manner that will reduce the public health burden of the childhood obesity pandemic.

Recommendations for exercise and screening for safe athletic participation in hypertensive youth

Physical activity is an important component of ideal cardiovascular health. Current guidelines recommend that youth with hypertension participate in competitive sports once hypertensive target organ effects and risks have been assessed and that children with hypertension receive treatment to lower BP below stage 2 thresholds (e.g., < 140/90 mmHg or < 95th percentile + 12 mmHg) before participating in competitive sports. Despite these recommendations, pediatricians and pediatric subspecialists continue to struggle with how best to counsel their patients regarding appropriate forms of physical activity, the impact of exercise on blood pressure, and how best to screen for cardiovascular conditions that place youth at risk for sudden cardiac death. This review provides a summary of our current knowledge regarding the safety and utility of exercise in the management of high blood pressure in youth. We review determinants of blood pressure during exercise, the impact of blood pressure on cardiovascular health and structure, mechanisms for assessing cardiometabolic fitness (e.g., exercise stress test), contraindications to athletic participation, and how best to plan for athletic participation among hypertensive youth. Greater knowledge in these areas may offer clarity to providers faced with the challenge of prescribing exercise recommendations for hypertensive youth.

Progression to hypertension in youth and young adults with type 1 or type 2 diabetes: The SEARCH for Diabetes in Youth Study

Central obesity may contribute to the development of hypertension in youths with diabetes. The SEARCH for Diabetes in Youth Study followed 1518 youths with type 1 diabetes (T1D) and 177 with type 2 diabetes (T2D) diagnosed when <20 years of age for incident hypertension. Incident hypertension was defined as blood pressure ≥95th percentile (or ≥130/80 mm Hg) or reporting antihypertensive therapy among those without hypertension at baseline. Poisson regression models were stratified by diabetes type and included demographic and clinical factors, clinical site, and waist‐to‐height ratio (WHtR). Youths with T2D were more likely to develop hypertension than those with T1D (35.6% vs 14.8%, P < .0001). For each 0.01 unit of annual increase in WHtR, adjusted relative risk for hypertension was 1.53 (95% CI 1.36‐1.73) and 1.20 (95% CI 1.00‐1.43) for youths with T1D and T2D, respectively. Effective strategies targeted toward reducing central obesity may reduce hypertension among youths with diabetes.

Development of a prediction model to target screening for high blood pressure in children

Targeted screening for childhood high blood pressure may be more feasible than routine blood pressure measurement in all children to avoid unnecessary harms, overdiagnosis or costs. Targeting maybe based e.g. on being overweight, but information on other predictors may also be useful. Therefore, we aimed to develop a multivariable diagnostic prediction model to select children aged 9-10 years for blood pressure measurement. Data from 5359 children in a population-based prospective cohort study were used. High blood pressure was defined as systolic or diastolic blood pressure ≥ 95th percentile for gender, age, and height. Logistic regression with backward selection was used to identify the strongest predictors related to pregnancy, child, and parent characteristics. Internal validation was performed using bootstrapping. 227 children (4.2%) had high blood pressure. The diagnostic model included maternal hypertensive disease during pregnancy, maternal BMI, maternal educational level, parental hypertension, parental smoking, child birth weight standard deviation score (SDS), child BMI SDS, and child ethnicity. The area under the ROC curve was 0.73, compared to 0.65 when using only child overweight. Using the model and a cut-off of 5% for predicted risk, sensitivity and specificity were 59% and 76%; using child overweight only, sensitivity and specificity were 47% and 84%. In conclusion, our diagnostic prediction model uses easily obtainable information to identify children at increased risk of high blood pressure, offering an opportunity for targeted screening. This model enables to detect a higher proportion of children with high blood pressure than a strategy based on child overweight only.

Prevalence of hypertension among school going adolescent boys in Najafgarh, Delhi, India

INTRODUCTION

Hypertension is a global epidemic. Hypertension has become an increasingly important medical problem in children and adolescents. Evidence shows that hypertension begins in childhood and its associated risk factors like obesity, unhealthy eating habits also emerge in children of school going age.

OBJECTIVES

To study the prevalence of hypertension among school going adolescent boys in Najafgarh, Delhi and to find out the factors associated with hypertension among them.

MATERIALS AND METHODS

A cross-sectional study was planned in which a self-administered questionnaire was used to collect information from the study participants. A total of 600 adolescent boys of 9th to 12th classes from four different schools in Delhi, were included in the study over a period of 12 months. Blood pressure, height, weight and waist circumference were measured for all children. Data was analyzed using SPSS software version 21.0 and for qualitative data analysis a chi-square (χ²) test was used.

RESULTS

The mean age of study subjects was 15.1 years. The majority of the study subjects, 372 (62%), were in the age group of 14-16 years. Among the study subjects, 44 (7.3%) had pre-hypertension and 26 (4.3%) had hypertension. Hypertension was significantly higher in those with a family history of hypertension and who were overweight/obese.

CONCLUSION

The prevalence of hypertension was significantly high among adolescents of Delhi. Obesity and family history of hypertension were identified as important risk factors prevalent in the study population.

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

In 2017, the American Academy of Pediatrics (AAP) updated the clinical practice guideline for high blood pressure (BP) in the pediatric population. In this study, we compared the difference in prevalence of elevated and hypertensive BP values defined by the 2017 AAP guideline and the 2004 Fourth Report and estimated the cardiovascular risk associated with the reclassification of BP status defined by the AAP guideline. A total of 47 200 children and adolescents aged 6 to 17 years from 6 countries (China, India, Iran, Korea, Poland, and Tunisia) were included in this study. Elevated BP and hypertension were defined according to 2 guidelines. In addition, 1606 children from China, Iran, and Korea who were reclassified upward by the AAP guideline compared with the Fourth Report and for whom laboratory data were available were 1:1 matched with children from the same countries who were normotensive by both guidelines. Compared with the Fourth Report, the prevalence of elevated BP defined by the AAP guideline was lower (14.9% versus 8.6%), whereas the prevalence of stages 1 and 2 hypertension was higher (stage 1, 6.6% versus 14.5%; stage 2, 0.4% versus 1.7%). Additionally, comparison of laboratory data in the case-control study showed that children who were reclassified upward were more likely to have adverse lipid profiles and high fasting blood glucose compared with normotensive children. In conclusion, the prevalence of elevated BP and hypertension varied significantly between both guidelines. Applying the new AAP guideline could identify more children with hypertension who are at increased cardiovascular risk.

Performance of blood pressure measurements at an initial screening visit for the diagnosis of hypertension in children

Hypertension in children is defined as sustained elevated blood pressure (BP) over several visits. For the screening of hypertension, it is standard to obtain several BP readings at the initial visit. There is however no recommendation on the minimum number of readings needed. We evaluated the performance of BP readings obtained at one initial screening visit to predict the diagnosis of hypertension in children. In a school-based study conducted in Switzerland, BP was measured three times on up to three visits in 5207 children. Sensitivity, specificity, negative predictive value (NPV), and positive predictive value (PPV) of elevated BP at the initial screening visit for the identification of hypertension were estimated using the 1st, 2nd, and 3rd BP readings (R1, R2, R3), as well as (R1 + R2)/2 and (R1 + R2 + R3)/3). These performance indices were compared with the reference method (R2 + R3)/2. The ability of BP readings to discriminate children with and without hypertension was evaluated with receiver operating characteristic curve analysis. The prevalence of systolic/diastolic hypertension was 2.2%. The greatest performance to identify children with hypertension was obtained with R2 (sensitivity: 97%; specificity: 88%; PPV: 15%; NPV: 100%) and the reference method, (R2 + R3)/2 (sensitivity: 100%; specificity: 90%; PPV: 18%; NPV: 100%). The ability to discriminate using R1, R2, (R1 + R2)/2, and (R2 + R3)/2 for the identification of hypertension was strong (AUC: 0.89, 0.93, 0.92, and 0.95, respectively). Obtaining two BP readings and using only the second one at a screening visit may be sufficient as initial step for the identification of hypertension in children.