Pediatrics

CME Educational Objectives

1. Understand the method for the measurement of blood pressure in children.

2. Recognize the correct method for BP interpretation in childhood based on age, sex and height.

3. Identify the current recommendations for initial evaluation of children and adolescents with identified hypertension.

Elevated blood pressure is well-established as a major risk factor for the development of atherosclerotic cardiovascular disease in adults.¹ Veterans Administration clinical trials also definitively demonstrated that the treatment of high blood pressure diminished the risk for stroke and other cardiovascular diseases.² In children and adolescents, it is well known that very high elevation of blood pressure, usually due to an underlying cause such as renal disease, is associated with severe comorbidities such as encephalopathy, stroke, and congestive heart failure.³ More recently, it has also become clear that lower elevations of blood pressure, when persistent, are associated with atherosclerotic lesions in the aorta and the coronary arteries in autopsy studies,⁴ increased left ventricular mass,⁵ endothelial dysfunction,⁶ and increased carotid intimal-medial thickness,⁷ all important intermediate endpoints for cardiovascular disease. The longer-term relationship between childhood blood pressure levels and hard cardiovascular endpoints in adulthood is not clearly known. Franks et al studied the effect of childhood risk factors for cardiovascular disease on adult mortality in a cohort of Native Americans followed before 55 years of age.⁸ The investigators found that obesity, glucose intolerance, and hypertension in childhood were strongly and independently associated with increased rates of premature death. When the results of these various investigations are combined, it becomes clear that elevated blood pressure in childhood and adolescence is associated with both short- and long-term adverse consequences. This article reviews best practices for the identification and treatment of high blood pressure in the pediatric age range and is based on the rationale presented in the 4th report on blood pressure in children from the National Heart, Lung, and Blood Institute (NHLBI)⁹ and in the new NHLBI Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents.¹⁰