New blood pres­sure guide­lines set for chil­dren

Las Vegas Review-Journal - - | NEWS & PUZZLES - By Jane E. Brody New York Times News Ser­vice

Had Matthew Good­win’s blood pres­sure been checked at age 3, when it should have been, he most likely would have been spared a med­i­cal emer­gency a year later. He spent two weeks in the pe­di­atric in­ten­sive care unit while doc­tors tried to de­ter­mine why his blood pres­sure had spiked off the charts fol­low­ing mi­nor surgery.

Matthew turned out to have a con­gen­i­tal kid­ney dis­or­der that caused se­vere hy­per­ten­sion and re­quired sur­geons to re­move one of his kid­neys and im­plant it in a new lo­ca­tion, a pro­ce­dure known as a kid­ney au­to­trans­plant. Now a 15-year-old hon­ors stu­dent from Prairieville, La., Matthew takes pres­sure-low­er­ing med­i­ca­tion and ad­heres closely to a low-sodium diet loaded with fresh fruits and veg­eta­bles and no soft drinks.

Know­ing his ex­pe­ri­ence is not unique and that mil­lions of young Amer­i­cans with el­e­vated blood pres­sure don’t know they have it, Matthew, who hopes to be­come a pe­di­atric nephrol­o­gist, vol­un­teers for the National Pe­di­atric Blood Pres­sure Aware­ness Foun­da­tion, a non­profit ad­vo­cacy group his mother, Ce­leste Good­win, cre­ated to ed­u­cate par­ents and pro­fes­sion­als about the im­por­tance of reg­u­lar blood pres­sure checks in chil­dren and ado­les­cents.

Boost­ing this ef­fort, in Au­gust the Amer­i­can Academy of Pe­di­atrics pub­lished a 74-page re­port up­dat­ing its guide­lines for screen­ing and man­ag­ing high blood pres­sure in young­sters. The re­port in­cludes a much-sim­pli­fied chart to help physi­cians read­ily de­ter­mine whether a child’s blood pres­sure is within nor­mal pa­ram­e­ters.

Just as chil­dren’s blood pres­sure can­not be mea­sured with a cuff meant for an adult-size arm, it also can­not be in­ter­preted on an adult scale.

For chil­dren, the def­i­ni­tion of nor­mal blood pres­sure is not based on a sim­ple read­ing of sys­tolic over di­as­tolic blood pres­sure, like 110 over 70 or 120 over 80. Rather, be­cause nor­mal blood pres­sure varies with a child’s age, gen­der and height, doc­tors typ­i­cally needed to con­sult pages of charts to de­ter­mine whether a pa­tient’s pres­sure was nor­mal or not.

Now, the new guide­lines pro­vide a short, easy-to-use ta­ble based only on a child’s gen­der and age, from 3 to 18, that doc­tors can read­ily con­sult and even hang in the of­fice where they and par­ents can see it.

Study after study has demon­strated that el­e­vated blood pres­sure is cor­rectly di­ag­nosed in less than one-quar­ter of the chil­dren who have it. For ex­am­ple, the largest study, pub­lished last year in the journal Pe­di­atrics, cov­ered more than 1.2 mil­lion pa­tients ages 3 to 18. Elec­tronic health records showed that 398,079 had their blood pres­sure mea­sured at three or more vis­its. Of these, read­ings in 12,138 chil­dren met the cri­te­ria for hy­per­ten­sion and 38,874 for pre-hy­per­ten­sion (now called el­e­vated blood pres­sure). But only 23.2 per­cent with hy­per­ten­sion and 10.2 per­cent with pre-hy­per­ten­sion were di­ag­nosed as such and duly noted for follow-up in their health records.

Dr. David Kael­ber, a pe­di­a­tri­cian and in­ternist at the MetroHealth Sys­tem in Cleve­land who di­rected the study and was co-chair­man of the team that de­vel­oped the new guide­lines, said in an in­ter­view, “It’s great to have guide­lines, but they’re only as good as the peo­ple who ac­tu­ally follow them.”

You may won­der why a di­ag­no­sis of high or el­e­vated blood pres­sure in chil­dren is im­por­tant. Al­though chil­dren don’t usu­ally suf­fer the con­se­quences of high blood pres­sure in the pe­di­atric years, Kael­ber said, un­less treated, it can re­sult in early heart at­tacks, strokes and kid­ney dis­ease.

El­e­vated blood pres­sure in chil­dren pre­dicts high blood pres­sure in adults, a lead­ing risk fac­tor for heart at­tacks and strokes. Al­ready in young adults who’ve had el­e­vated blood pres­sure as chil­dren, “you can see two kinds of car­dio­vas­cu­lar dam­age,” Dr. Joseph T. Flynn, lead au­thor of the new guide­lines, said in an in­ter­view. “There is thick­en­ing of the left ven­tri­cle, the heart’s main pump­ing cham­ber, and thick­en­ing of blood ves­sel walls that is clearly tied to ath­er­o­scle­ro­sis and heart at­tacks in adults.”

Be­cause high blood pres­sure of­ten runs in fam­i­lies, de­tect­ing it in a child may prompt a check of the par­ents and other fam­ily mem­bers and end up sav­ing their health and lives, Flynn said.

And as demon­strated by Matthew Good­win’s ex­pe­ri­ence, in about 20 per­cent of cases there is an un­der­ly­ing and cor­rectable cause for high blood pres­sure in chil­dren. Fail­ing to make the cor­rect di­ag­no­sis can be dis­as­trous. As his mother put it bluntly, “Matthew could have died.”

The preva­lence of el­e­vated blood pres­sure and frank hy­per­ten­sion in chil­dren and ado­les­cents has risen dra­mat­i­cally in re­cent decades, largely the re­sult of in­creas­ing over­weight and obe­sity in the young. An es­ti­mated 17 per­cent of chil­dren aged 2 to 19 are obese, and ap­prox­i­mately 2 mil­lion chil­dren have hy­per­ten­sion.

Other con­trib­u­tors to the preva­lence of hy­per­ten­sion in chil­dren in­clude a grow­ing de­pen­dence on fast foods, pro­cessed foods and snacks that are high in salt, caus­ing ex­cess sodium and fluid in the blood and an added strain on the del­i­cate blood ves­sels that feed the kid­neys.

The new guide­lines from the pe­di­atric academy urge health care prac­ti­tion­ers to mea­sure and record blood pres­sure at ev­ery well-child or preven­tive care visit, whether or not the child is over­weight or there ap­pears to be any­thing wrong. If the blood pres­sure read­ing is recorded in an elec­tronic health record, the com­puter does the nec­es­sary cal­cu­la­tion to de­ter­mine if the read­ing is nor­mal.

To pre­vent this exam from be­ing over­looked, Kael­ber sug­gested that par­ents gen­tly nudge the prac­ti­tioner by ask­ing, “By the way, how is my child’s blood pres­sure do­ing?”

PAUL ROGERS / THE NEW YORK TIMES

Stud­ies have shown that high blood pres­sure is cor­rectly di­ag­nosed in less than one-quar­ter of the chil­dren who have the el­e­vated read­ings.

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