Hypertension: Screening -- Children and Adolescents


General

Grade: I The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of the service. Evidence is lacking, of poor quality, or conflicting, and the balance of benefits and harms cannot be determined. Read the clinical considerations section of USPSTF Recommendation Statement. If the service is offered, patients should understand the uncertainty about the balance of benefits and harms.

Specific Recommendations

The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for primary hypertension in asymptomatic children and adolescents to prevent subsequent cardiovascular disease in childhood or adulthood.

Frequency of Service

Several organizations recommend routine screening of blood pressure at well-child visits starting at age 3 years, based on consensus.

Risk Factor Information

The strongest risk factor for primary hypertension in children and adolescents is elevated body mass index. Other risk factors include low birhweight, male sex, ethnicity, and family history of hypertension.


Clinical

Patient Population Under Consideration

This recommendation applies to children and adolescents who do not have symptoms of hypertension.

Assessment of Risk

The strongest risk factor for primary hypertension in children and adolescents is elevated body mass index. Other risk factors include low birhweight, male sex, ethnicity, and family history of hypertension.

Suggestions for Practice Regarding the I Statement

In deciding whether to screen children and adolescents for hypertension, clinicians should consider the following.

Potential Preventable Burden

The increasing prevalence of hypertension in children and adolescents, possibly driven by childhood obesity, suggests that identification and treatment of hypertension is likely to become a significant health care issue. The goal of identifying and treating children and adolescents with primary hypertension can be viewed within a larger framework of adult cardiovascular risk reduction, which includes addressing other biometric risk factors, such as elevated body mass index and lipid profiles and hyperglycemia. The variables for cardiovascular risk reduction in adults are better understood because hypertension in adults is defined by relatively consistent quantitative thresholds, the epidemiologic evidence demonstrates the association between hypertension and subsequent cardiovascular risk, and treatment trials have shown that reduction in blood pressure reduces the risk for cardiovascular events in older adults.

Extending the adult framework for cardiovascular risk reduction to children and adolescents is limited by several methodological challenges that complicate determining the potential preventable burden. Blood pressure percentiles are used to define normative values for children and adolescents, and less is known about the clinical and epidemiologic significance of these thresholds in terms of their association with adult cardiovascular disease. In addition, the performance characteristics of current methods for diagnosing hypertension during childhood are limited and of concern because of false-positive rates (blood pressure measurements that later normalize). Evidence on the association between childhood blood pressure and adult hypertension is limited, as is evidence on the longitudinal association between childhood blood pressure and other markers of adult cardiovascular disease.

Most important, the limited data on treatment of hypertension in children and adolescents do not include longer-term follow-up to show reductions in surrogate, subclinical, or clinical measures of cardiovascular disease in either later adolescence or young adulthood. This limited evidence base makes it difficult to quantify the true significance and consequences of a hypertension diagnosis in children and adolescents and the potential benefit of early intervention.

One rationale that has been suggested for screening is to identify secondary hypertension—a relatively rare condition resulting from another underlying cause, such as renal parenchymal disease or renovascular disease. Younger children are more likely than older children and adolescents to have a secondary cause of hypertension; a recent study suggests that secondary causes of hypertension are significantly more common in children younger than 6 years than in older children. Secondary hypertension is unlikely to be the only clinical manifestation of the underlying disorder in these cases, and management is primarily targeted at treating the underlying condition, as well as controlling hypertension. As children age into adolescence, 85% to 95% of all hypertension diagnoses are considered primary.

Potential Harms

Although 1 good-quality study suggests that no adverse effects are associated with hypertension detection in childhood, the evidence on the diagnostic accuracy of clinic-based screening for hypertension suggests that false-positive results may occur. Thus, unnecessary secondary evaluations or treatments may be common, particularly with frequent blood pressure screening. Pharmacologic interventions have been shown to be well-tolerated over relatively short periods. Treatment of hypertension in childhood and adolescence with pharmacologic agents is done for a much longer period, and adverse effects of such pharmacotherapy can occur.

Current Practice

Current screening practice for elevated blood pressure typically involves measurement of blood pressure in office-based health care settings as part of well-child or sports preparticipation examinations, often in conjunction with other vital signs and growth parameters. The National High Blood Pressure Education Program (NHBPEP) percentile charts are used to interpret systolic blood pressure (SBP) and diastolic blood pressure (DBP) measurements and categorize them as normal, prehypertension, or hypertension on the basis of the child's age, height, and sex for each year of the child's life from age 3 to 18 years.

A 2012 study analyzing data from the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey assessed blood pressure screening during pediatric ambulatory office visits. It found that screening was done during 67% of preventive care visits and 35% of ambulatory visits. Screening was more common in children who were overweight or obese; 84% of these preventive care visits included screening for hypertension. It was also more likely to be done in older children.

Screening Tests

The consensus-based guidelines of the NHBPEP and National Heart, Lung, and Blood Institute define hypertension in children on the basis of percentiles according to age, height, and sex. Hypertension is defined as SBP or DBP at or above the 95th percentile. Hypertension is classified as stage 1 (SBP or DBP from 95th to 99th percentile, plus 5 mm Hg) or stage 2 (SBP or DBP >99th percentile, plus 5 mm Hg). The NHBPEP provides guidance on optimal blood pressure measurement techniques, such as appropriate cuff size and type of sphygmomanometer. Blood pressure should be measured in a controlled environment after 5 minutes of rest, with the patient seated and the right arm supported at heart level.

Treatment

Stage 1 hypertension in children is treated with lifestyle and pharmacologic interventions. Medications are not recommended as first-line therapy. Lifestyle interventions for hypertension include weight reduction in children who are overweight or obese, increased physical activity, and restricted sodium intake, as well as education and counseling. The NHBPEP recommends medication for children with stage 2 hypertension or for hypertension that is unresponsive to lifestyle modification.

Many medications have been approved by the U.S. Food and Drug Administration for the treatment of hypertension in children, including diuretics, angiotensin-converting enzyme inhibitors, angiotensin-receptor blockers, β-blockers, and vasodilators.

Screening Intervals

Several organizations recommend routine screening of blood pressure at well-child visits starting at age 3 years, based on consensus. 

Other Considerations

Research Needs and Gaps

There are several critical evidence gaps in better understanding the potential net benefit of screening for hypertension in childhood and adolescence. Evidence about the accuracy and reliability of blood pressure screening tools and protocols in primary care among children and adolescents of varying ages and characteristics, such as those who are obese, is needed. Comparative accuracy studies that examine the different types of devices to measure blood pressure, such as newer devices that obtain several readings in 1 visit, home-based devices, and ambulatory blood pressure measurement, are needed. In addition, screening strategies that reduce the rate of false-positive diagnoses of hypertension need to be identified. Studies on the adverse effects of screening are also needed.

Prospective and retrospective cohort studies that include blood pressure measures and other cardiovascular risk factors in children and adolescents with long-term follow-up are needed to examine the adolescent and adult health outcomes of hypertension in childhood. Studies that elucidate the association among childhood hypertension, adult hypertension, and surrogate measures of cardiovascular disease in childhood and adulthood, as well as adult clinical cardiovascular disease, are also needed.

Most important, evidence to ascertain the effectiveness and comparative effectiveness of pharmacologic and lifestyle interventions to achieve sustained reductions in blood pressure and longer-term modification of adult hypertension and cardiovascular risk in children with primary hypertension is needed. Such studies should include longer follow-up intervals to determine the long-term effectiveness of these interventions in achieving sustained reductions in blood pressure during childhood and adolescence or reductions in future adult hypertension. Although trials with clinical cardiovascular end points are more challenging in children, treatment trials demonstrating changes in surrogate or subclinical cardiovascular outcomes during adolescence or young adulthood are feasible and warranted. Trials focusing on high-risk adolescent populations (such as those with obesity) that include longer-term follow-up with future hypertension and subclinical cardiovascular outcomes should be possible. Studies of treatment during childhood should include an assessment of medication harms, measures of long-term compliance, and study designs that examine individual components of multifactorial interventions.

Rationale

No information available.


Others

The American Academy of Pediatrics officially endorsed the NHBPEP 2004 recommendation that children aged 3 years and older have blood pressure measurement at least once at every “health care episode”. The National Heart, Lung, and Blood Institute's Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents recommends annual blood pressure screening in children from ages 3 to 17 years. Bright Futures and other organizations, such as the American Heart Association, recommend routine screening for increased blood pressure in children during annual well-child visits beginning at age 3 years. The American Academy of Family Physicians states that there is insufficient evidence for or against routine screening for high blood pressure in children and adolescents.


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