Tracking of Blood Pressure in Children and Adolescents in Germany in the Context of Risk Factors for Hypertension

Undiagnosed Pediatric Elevated Blood Pressure Is Characterized by Induction of Proinflammatory and Cytotoxic Mediators

BACKGROUND

Inflammatory processes have been suggested as a culprit of vascular damage in pediatric hypertension. We aimed to investigate transcriptional changes of immune modulators and determine their association with office blood pressure in adolescents who were not diagnosed with hypertension at the time of the study visit.

METHODS

Office blood pressure measurements and blood samples were taken from adolescents of 2 German birth cohorts, GINIplus (The German Infant Study on the Influence of Nutrition Intervention Plus Air Pollution and Genetics on Allergy Development; discovery cohort, n=1219) and LISA (Influences of Lifestyle-related factors on the Immune System and the Development of Allergies in Childhood; validation cohort, n=809), during the 15-year follow-up visit and categorized based on the European Society of Hypertension Guideline. Hs-CRP (high-sensitivity C-reactive protein) and expression of 51 genes encoding cytokines/receptors and transcription factors were analyzed.

RESULTS

The prevalence of elevated systolic blood pressure (overweight/obese) was 14.0% (5.1%) and 16.4% (5.2%) in the discovery and validation cohorts, respectively. An enhanced cytotoxic (GZMB, PRF1, IL2RB) and proinflammatory (FOS, IL1B, hs-CRP) immune profile was observed in association with the hypertension class in both cohorts. Expression of hs-CRP and IL1B was driven by overweight with IL1B being identified as a mediator between body mass index and elevated systolic blood pressure (adj.β/95% CI, 0.01/0.0002-0.02). The association of GZMB (adjusted odds ratio/95% CI, 1.67/1.26-2.21; P=0.0004) and PRF1 (adjusted odds ratio/95% CI, 1.70/1.26-2.29; P=0.0005) in the hypertension class remained significant in normal-weight individuals without parental predisposition. These effects were confirmed in LISA.

CONCLUSIONS

Adolescent hypertension is not limited to known risk groups. As adolescents in the hypertension class show an inflammatory profile similar to that of established hypertension in adults, blood pressure monitoring at a young age is critical to ensure early intervention and prevention of adverse sequelae.

Incidence of Arterial Hypertension is Associated with Adiposity in Children and Adolescents

BACKGROUND

The increase of hypertension in children and adolescents has attracted the attention of the scientific community largely due to its association with the obesity epidemic.

OBJECTIVES

To describe the incidence of hypertension and its relationship with the cardiometabolic and genetic profile in children and adolescents from a city in southern Brazil in a three-year period.

METHODS

This longitudinal study followed 469 children and adolescents, aged 7-17 years old (43.1% boys), assessed at two-time points. We evaluated systolic and diastolic blood pressures (SBP and DBP), waist circumference (WC), body mass index (BMI), body fat percentage (%BF), lipid profile, glucose, cardiorespiratory fitness (CRF), and rs9939609 Polymorphism ( FTO ). Cumulative incidence of hypertension was calculated, and multinomial logistic regression was conducted. The statistical significance was established as p < 0.05.

RESULTS

After three years, the incidence of hypertension was 11.5%. Overweight or obese individuals were more likely to become borderline hypertensive (overweight OR: 3.22, 95% CI: 1.08-9.55; obesity OR: 4.05, 95% CI: 1.68-9.75), and obese individuals were more likely to become hypertensive (obesity OR: 4.84, 95% CI: 1.57-14.95). High-risk WC and %BF values were associated with hypertension development (OR: 3.41, 95% CI: 1.26-9.19; OR: 2.49, 95% CI: 1.08-5.75, respectively).

CONCLUSIONS

We found a higher incidence of hypertension in children and adolescents as compared with previous studies. Individuals with higher values of BMI, WC and %BF at baseline were more likely to develop hypertension, suggesting the importance of adiposity in the development of hypertension even in such a young population.

Persistence and determinants of blood pressure phenotypes according to office and ambulatory blood pressure measurements in youth

Ambulatory BP monitoring is increasingly used in children and adolescents, and the persistence of discrepant phenotypes, such as white coat or masked hypertension, is a relevant issue. The objective of this study was to assess the persistence of BP phenotypes over time and the factors related to their persistence. The study included 582 children and adolescents (9.4  ±  2.8 years of age) of both sexes (51% females) referred for routine health maintenance. Anthropometric parameters and office and 24-h ABPM measurements were obtained twice (interval 19.5  ±  6.9 months). BP classification and phenotypes were qualified using the 2016 ESH Guidelines. The correlation coefficient and kappa statistics were used to assess the persistence of phenotypes, and the related factors were evaluated using logistic regression. Based on both systolic and diastolic BP measurements, 91.6%, 16%, 17.2% and 13.7% of the subjects with true normotension, sustained HTN, white coat HTN and masked HTN, respectively, remained in the same category (overall agreement 74.2%, kappa 0.20). The multivariate model predicted the lack of persistence and correctly classified 90.3% of the subjects, with the pathological baseline BP phenotype (mainly masked HTN) being the independent variable that contributed most to the model. Excluding the phenotypes, the rest of the model explained 14% of the lack of persistence, and a high office SBP and high waist circumference were related to the lack of persistence. Furthermore, subjects who experienced an increase in their BMI z score and change in their BMI category were at risk of a lack of persistence. In conclusion, children, especially those with BP phenotypes different from true normotension, should be re-evaluated because a large percentage are likely to become normotensive.

Lymphocyte to monocyte ratio and blood pressure variability in childhood hypertension-a pilot study

BACKGROUND AND AIMS

The investigation of inflammatory background of hypertension (HTN) concentrates mainly on patients with primary HTN. The aim of the study was to analyze the role of new parameters of inflammation-lymphocyte to monocyte ratio (LMR), neutrophil to lymphocyte ratio (NLR), and platelet to lymphocyte ratio (PLR), in the population of children with primary (pHTN) and secondary renal hypertension (rHTN).

MATERIAL AND METHODS

The study group consisted of 70 children with pHTN, 46 patients with rHTN, and 30 age-matched normotensive controls. The retrospective analysis focused on the evaluation of LMR, NLR, and PLR values in relation to blood pressure (BP) parameters from in-office and ambulatory BP monitoring measurements. Twenty-four hours, daytime, and nighttime periods were evaluated. Blood pressure variability (BPV) was defined by standard deviation and coefficient of variation of analyzed values.

RESULTS

LMR and NLR values in HTN patients differed significantly vs. controls. Dippers with pHTN demonstrated significant correlations between LMR, NLR, PLR, and markers of BPV, in 24 h and daytime diastolic BP and mean arterial pressure. In dippers with rHTN such correlations concerned only LMR.

CONCLUSIONS

LMR may become a promising marker of BPV, useful in children with primary and secondary hypertension.

IMPACT

Lymphocyte to monocyte ratio is a novel marker of blood pressure variability, connected to target-organ damage, in children with primary and secondary renal hypertension. Our study analyzes for the first time the connections between blood cell count-driven inflammatory markers (lymphocyte to monocyte, neutrophil to lymphocyte, and platelet to lymphocyte ratios) and parameters of blood pressure variability, and compares those ratios in children with primary and secondary hypertension. The increasing incidence of hypertension among children urges the search for simple methods of assessment of its complications. LMR may be of added value in the analysis of the inflammatory background of hypertension.

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.

Temporal Associations between Tri-Ponderal Mass Index and Blood Pressure in Chinese Children: A Cross-Lag Analysis

Background: No longitudinal studies have explored the relationship between tri-ponderal mass index (TMI) and blood pressure (BP) in children. This study is aimed to investigate the temporal associations between TMI and BP among children in China. Methods: A longitudinal study was carried out with Chinese children from 2014 to 2019. Data of the anthropometric examination and blood pressure were collected annually. TMI was calculated by dividing weight by the cube of height. BP was measured using a standard mercury sphygmomanometer. We investigated temporal associations between TMI and BP with a cross-lagged panel model using repeated measure data from 2014 (Wave 1), 2016 (Wave 2), and 2018 (Wave 3). Results: Results of the cross-lagged panel model showed that TMI was associated with subsequent BP. Participants with higher levels of TMI presented higher levels of BP (Wave 1: β = 0.737 for systolic blood pressure (SBP) and β = 0.308 for diastolic blood pressure (DBP), Wave 2: β = 0.422 for SBP and β = 0.165 for DBP, p < 0.01). In addition, children with higher BP could also present higher TMI (Wave 1: β = 0.004 for SBP and β = 0.006 for DBP, Wave 2: β = 0.003 for SBP and β = 0.005 for DBP, p < 0.01), but the cross-lag path coefficient indicated that the influence of TMI on BP was stronger than the influence of BP on TMI. Conclusions: There was a temporal association between TMI and BP in Chinese children. Higher TMI predicted higher subsequent BP rather than the reverse relationship.

Increased Physical Activity at School Benefits Arterial Blood Pressure in Children-A Prospective Follow-Up Cohort Study

(1) Background: A sedentary lifestyle and low physical activity (PA) increase the risk of hypertension in children. The aim of this study was to assess the impact of increased PA at school by elevation of the number of compulsory physical education (PE) lessons on arterial blood pressure in children during a two-year follow-up. (2) Methods: Children (n = 245) born in 2007 attending a standard or elevated number of PE lessons in the school timetable (4 and 10 h a week, respectively) took part in the study. Blood pressure was measured starting from age approx. 10 to 12. (3) Results: Starting from a similar level, after 2 years, the percentage of children with normal blood pressure decreased in the standard-PE children from 83.25% to 78.03% but increased in the elevated-PE ones from 83.15% to 86.13%. The prevalence of both prehypertension and hypertension increased by one-third in the standard-PE children from 16.74% to 21.97% but decreased by one-sixth in the elevated-PE ones from 16.85% to 13.87%. The prevalence of hypertension itself increased by one-third in the standard-PE children from 9.82% to 13.12% but decreased in the elevated-PE ones by one-fifth from 9.60% to 7.75% (4) Conclusions: An increase in PA at school by the elevation of the number of PE lessons benefits children's arterial blood pressure. Early prevention of hypertension in children can be supported by an adequate number of PE lessons in the school timetable.

Trajectories of Systolic Blood Pressure in Children: Risk Factors and Cardiometabolic Correlates

OBJECTIVE

To identify systolic blood pressure (SBP) percentile trajectories in children and to describe the early-life risk factors and cardiometabolic correlates of those trajectories.

STUDY DESIGN

Using age-, sex-, and height-specific SBP percentiles based on the American Academy of Pediatrics reference, we examined SBP trajectories using latent class mixed models from ages 3 to 8 years (n = 844) from the Growing Up in Singapore Towards healthy Outcomes-study, a Singaporean mother-offspring cohort study. We analyzed associations between SBP trajectories and early-life risk factors using multinomial logistic regression and differences across trajectories in cardiometabolic outcomes using multiple linear regression.

RESULTS

Children were classified into 1 of 4 SBP percentile trajectories: "low increasing" (15%), "high stable" (47%), "high decreasing" (20%), and "low stable" (18%). Maternal hypertension during early pregnancy was a predictor of the "high stable" and "low increasing" SBP trajectories. Rapid child weight gain in the first 2 years of life was only associated with the "high stable" trajectory. Compared with children in the "low stable" trajectory, children in the "high stable" SBP trajectory had greater body mass index z scores, sum of skinfold thicknesses, waist circumference from ages 3 to 8 years, and abdominal adipose tissue (milliliters) at 4.5 years (adjusted mean difference [95% CI]: superficial and deep subcutaneous abdominal adipose tissue: 115.2 [48.1-182.3] and 85.5 [35.2-135.8]). Their fat mass (kilograms) (1.3 [0.6-2.0]), triglyceride levels (mmol/L) (0.10 [0.02-0.18]), and homeostasis model assessment of insulin resistance (0.28 [0.11 0.46]) at age 6 years were also greater but not their arterial thickness and stiffness.

CONCLUSIONS

Reducing maternal blood pressure during pregnancy and infant weight gain in the first 2 years of life might help to prevent the development of high SBP.

Neutrophil to Lymphocyte Ratio Is Increased and Associated With Left Ventricular Diastolic Function in Newly Diagnosed Essential Hypertension Children

Aim: Hypertension is associated with cardiac structural and functional changes, including left ventricular hypertrophy (LVH) and LV systolic dysfunction diastolic dysfunction. Neutrophil-to-lymphocyte ratio (NLR) is a novel inflammatory biomarker associated with cardiovascular diseases. The current study aimed to evaluate NLR in children with newly diagnosed essential hypertension and its relationship between blood pressure and cardiac changes. Methods and Subjects: Sixty-five children with newly diagnosed essential hypertension and 54 healthy children were included. Clinical characteristics, blood cell counts, and biochemical parameters were collected. LVH was assessed by calculation of LV mass index (LVMI), and LV systolic function was evaluated by measuring LV ejection fraction and fractional shortening. LV diastolic function was primarily assessed with E/E' ratio by Doppler and echocardiography. Results: The hypertension children had significantly higher LVMI and E/E' ratio than the controls, whereas there was no difference in LV systolic function between the two groups. The NLR was significantly higher in the hypertension group than the control group. Moreover, NLR was positively correlated with systolic blood pressure (SBP) and diastolic blood pressure (DBP) levels in the hypertension group. Additionally, a significantly positive correlation between NLR and E/E' ratio was found in the hypertension group. However, NLR was not related to LVH and LV systolic function indicators in hypertension children. Conclusion: NLR is elevated in hypertension children, and it is associated positively with office blood pressure levels. Moreover, NLR may help assess LV diastolic function in hypertension children.

Blood pressure and resting heart rate in 3-17-year-olds in Germany in 2003-2006 and 2014-2017

To track blood pressure (BP) and resting heart rate (RHR) in children and adolescents is important due to its associations with cardiovascular outcomes in the adulthood. Therefore, the aim of this study was to examine BP and RHR over a decade among children and adolescents living in Germany using national examination data. Cross-sectional data from 3- to 17-year-old national survey participants (KiGGS 2003–06, n = 14,701; KiGGS 2014–17, n = 3509) including standardized oscillometric BP and RHR were used for age- and sex-standardized analysis. Measurement protocols were identical with the exception of the cuff selection rule, which was accounted for in the analyses. Different BP and RHR trends were observed according to age-groups. In 3- to 6-year-olds adjusted mean SBP and DBP were significantly higher in 2014–2017 compared to 2003–2006 (+2.4 and +1.9 mm Hg, respectively), while RHR was statistically significantly lower by −3.8 bpm. No significant changes in BP or in RHR were observed in 7- to 10-year-olds over time. In 11- to 13-year-olds as well as in 14- to 17-year-olds lower BP has been observed (SBP −2.4 and −3.2 mm Hg, respectively, and DBP −1.8 and −1.7 mm Hg), while RHR was significantly higher (+2.7 and +3.7 bpm). BP trends did not parallel RHR trends. The downward BP trend in adolescents seemed to follow decreasing adult BP trends in middle and high-income countries. The increase in BP in younger children needs confirmation from other studies as well as further investigation. In school-aged children and adolescents, the increased RHR trend may indicate decreased physical fitness.

Cardiovascular Risk Factors and Their Relationship with Vascular Dysfunction in South African Children of African Ancestry

Vascular dysfunction is known to be an initiator of the development and progression of cardiovascular diseases (CVDs). However, there is paucity of information on the relationship of vascular dysfunction with cardiovascular risk factors in children of African ancestry. This study investigated the relationship between cardiovascular risk factors and vascular function in South African children of African ancestry. A cross-sectional study on 6–9-year-old children in randomly selected rural and urban schools of the Eastern Cape Province of South Africa was conducted. General anthropometric indices were measured, followed by blood pressure (BP) measurements. The pulse wave velocity (PWV) was measured using a Vicorder. Albumin to creatinine ratio (ACR), asymmetric dimethylarginine (ADMA), 8-hydroxy-2deoxyguanosine (8-OHdG) and thiobarbituric acid reactive substance (TBARS) were assayed in urine. Children from urban settings (10.8%) had a higher prevalence of overweight/obesity than their rural counterparts (8.5%) while the prevalence of elevated/high blood pressure was higher in rural (23.2%) than urban children (19.0%). Mean arterial blood pressure (MAP) and diastolic blood pressure (DBP) increased with increasing PWV (p < 0.05). Body mass index (BMI), diastolic blood pressure (DBP) and mean arterial blood pressure (MAP) positively associated (p < 0.05) with PWV. Creatinine, albumin and ACR significantly (p < 0.005) increased with increasing ADMA. ADMA associated positively (p < 0.05) with creatinine and 8-OHdG. In conclusion, vascular dysfunction was associated with obesity, high blood pressure, oxidative stress and microalbuminuria in South African children of African ancestry.

In utero and postnatal exposure to environmental tobacco smoke, blood pressure, and hypertension in children: the Seven Northeastern Cities study

To evaluate the association of environmental tobacco smoke (ETS) exposure with hypertension and blood pressure (BP) in children, a sample of 9,354 children, aged 5-17 years, was studied from seven northeastern cities of China in 2012-2013. The results showesd that significant associations were observed for hypertension with ETS exposure in utero [odds ratio (OR) 1.36, 95% confidence interval (CI) 1.18-1.57], with current major ETS exposure from fathers (1.38, 1.21-1.57) or anyone (1.26, 1.12-1.42), and with intensity of ETS exposure greater than 1 cigarette per day (ORs ranged from 1.20 to 1.35). For SBP, significant associations were only observed in children with major ETS exposure from father and with cigarettes smoking >10/day. When stratified by sex, more significant associations were found in girls than in boys. In conclusion, prenatal and postnatal ETS exposure was significantly associated with increased odds of hypertension in children, especially in girls.

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.