Pediatric hypertension is complex and often related to weight, activity level, caffeine intake, medication exposure, anxiety, and chronic illness.1 Because pediatric hypertension is still relatively rare, many pediatricians do not routinely follow the guidelines for management of blood pressure despite the long-term health risks associated with uncontrolled elevated blood pressure.2 To increase awareness of the management of pediatric hypertension, we discuss a patient who was evaluated several times during an 8-month period without proper blood pressure intervention. We discuss the diagnosis and updated 2017 blood pressure management guidelines released by the American Academy of Pediatrics.
A 16-year-old girl presented to her primary care clinic for an adolescent health visit. Her last well-child visit was 2 years prior, at which time she had normal vital signs and physical examination. At this current visit, her blood pressure was elevated (148/97 mm Hg), and it was still similarly elevated during the manual recheck. Upon chart review, it was noted that this was her third documented elevated blood pressure over the course of the past 8 months. The previous two readings were 133/94 mm Hg taken the week prior at a visit to discuss birth control options and 144/100 mm Hg 8 months prior at a sick visit for viral pharyngitis. Regarding the rest of her health history, she had no significant past medical history apart from seasonal allergies for which she took antihistamines as needed. Her family history was noncontributory, apart from her maternal grandmother who was diagnosed with hyperthyroidism and her father who had been diagnosed with hypertension. Otherwise, there is no significant family history of renal disease, sudden cardiac death, cardiovascular disease, autoimmune disease, or genetic disorders. The patient does well in high school, is on a competitive dance team, and denies drug, cigarette, or alcohol use. Apart from her elevated blood pressure, she had no noted abnormalities on her physical examination. Her body mass index (BMI) was 17.3 kg/m2 (5.8%), weight 51.6 kg (34%), and height 165 cm (63%).
Based on her three elevated blood pressure readings that occurred at separate encounters, our patient was diagnosed with stage II hypertension.1 Laboratory evaluation was initiated to check for possible causes of her hypertension based on the American Academy of Pediatrics (AAP) Clinical Practice Guidelines.2 This included complete blood count, complete metabolic panel (CMP), thyroid-stimulating hormone, lipid panel, and urinalysis (UA). Her laboratory results were notable for hemoglobin of 6 g/dL, a CMP with blood urea nitrogen/creatinine levels of 68 mg/dL/11.5 mg/dL, serum calcium of 6 mg/dL, and a UA with 2+ protein. The only abnormality on her electrolyte panel was a carbon dioxide level of 15 mmol/L. Otherwise, her sodium, potassium, and other laboratory tests were normal.
Once her outpatient provider received these results, the patient was sent to the emergency department for concern for acute renal failure where she had repeat and additional testing, which included a renal ultrasound. The results were consistent with chronic kidney disease (CKD). Based on the pathology of a renal biopsy, she was diagnosed with focal segmental glomerulosclerosis. She was immediately placed on the kidney transplant list and remained stable during peritoneal dialysis until receiving her kidney transplant 6 months after initial diagnosis.
Hypertension can be insidious in onset with serious health consequences, especially in patients with no apparent risk factors for whom screening may be delayed.3 The updated guidelines call for a diagnosis of hypertension once a patient has three separate encounters that show auscultatory-confirmed blood pressure readings greater than or equal to the 95th percentile for one's age, sex, and height. The updated guidelines also simplified the diagnosis of hypertension for children age 13 years or older by applying a standard cutoff of 120/80 mm Hg for normal blood pressure.4 For children who are otherwise healthy, the AAP recommends only checking blood pressure at annual visits, not sick visits. Exceptions to this rule should be made for patients who have particular risk factors, which are listed in Table 1.
Indications to Check Blood Pressure More Frequently Than at the Annual Well-Child Visits
It is not surprising that the patient from our illustrative case had CKD that progressed to end-stage renal disease prior to her diagnosis without any symptoms.5,6 Renal disease often goes unrecognized as symptoms sometimes do not appear until the renal function is very low. She had a normal BMI, unremarkable health history, and was athletic—exercising regularly with her competitive dance team. The only universal laboratory evaluation recommended by the AAP for adolescents with healthy BMI and no cardiovascular disease risk factors is a one-time lipid profile between ages 17 and 21 years and sexually transmitted infections screening if someone is sexually active.7 Lipid profile is attained earlier in patients who have cardiovascular disease risk factors such as obesity or strong family history. The one clue that we had with this patient was that she had severely elevated blood pressure at a sick visit 8 months prior to her diagnosis. When a patient has a blood pressure consistent with stage 2 hypertension8 (≥140/90 mm Hg), the AAP guidelines recommend rechecking upper and lower extremity blood pressure manually and having the patient follow-up within 1 week with a primary care provider or a specialist.
Based on these recommendations, the patient in our illustrative case should have had a repeat blood pressure screen in 1 week after her initial elevated reading 8 months prior. This was a missed opportunity that would likely have led to earlier diagnosis of focal segmental glomerulosclerosis and interventions, which could have delayed the decline in renal function. Otherwise, she was appropriately managed with laboratory evaluation initiated after her third elevated blood pressure reading, which led to her diagnosis. For children with a first-time diagnosis of elevated blood pressure (ie, between 90th and 95th percentile) based on age, sex, and height (Table 2), the AAP recommends lifestyle modifications and repeat blood pressure measurement within 6 months. For children who meet criteria for stage 1 hypertension (Table 2), the AAP recommends repeat blood pressure measurement within 2 weeks. The goal of the screening guidelines is to avoid delay in diagnosis of stage 2 hypertension or delay in initiation of pharmacotherapy if indicated.8
A Call to Action
Researchers who are evaluating diagnostic errors in pediatrics have noted that pediatricians often fail to identify or appropriately act on elevated blood pressure readings.9 One of the main reasons identified is that the age/sex/height charts create an obstacle for clinicians, as they are viewed as cumbersome to use and time consuming to read.10 Some electronic medical records (EMR) have built the age-specific cut offs into their blood pressure algorithms so that children with elevated blood pressure are flagged, and clinicians can then look at the full chart to see the patient's actual percentile.9,10 Other studies have found that the majority of children who have a missed diagnosis of hypertension are those without any obvious risk factors such as obesity or family history of cardiovascular disease.11 Many clinicians also incorrectly apply the 120/80 mm Hg cutoff that is used for adolescents to younger children, and this was more likely to happen if the patient was seen by a nurse practitioner or someone with less training than a doctor.12 The patient in this illustrative case was seen twice by physician assistants prior to getting referred for laboratory testing at the third visit with the physician.
Despite efforts to improve EMR documentation, many studies have found that clinicians still fail to take appropriate action. A retrospective study from 2018,10 which looked at the health records of patients seen in 34 private practices, found that even if blood pressure was flagged by the EMR, clinicians failed to document the blood pressure percentile in their notes or add elevated blood pressure to a patient's problem list. For those patients who had elevated blood pressure without formal documentation by a provider, appropriate actions such as follow-up blood pressure checks or referral to a specialist were not taken.10 Many quality improvement studies have aimed to alleviate these errors and have found success with a multidisciplinary approach. For example, if a practice creates a blood pressure Quality Improvement (QI) team made up of physicians, other health care providers, and administrators, the group members can work together to chart review and to identify practice-specific causes of error.9 Other approaches include a combination of webinars, written materials such as wall posters, and listserv reminders to provide education and tools for providers to both learn about the screening guidelines and to provide visual in-office cues.9 Although this research is promising, the tools need to be more widespread to have a meaningful reduction on missed hypertension.
Take Home Points
It is important for pediatricians to understand the new recommendations for blood pressure screening, as we know hypertension is currently underestimated in the outpatient setting. Patients with stage 2 hypertension would benefit from earlier identification, close follow-up, and testing for secondary causes. There has been a recent increase in QI projects that aim to reduce the number of missed diagnoses of elevated blood pressure and hypertension. We hope that continued education for health care providers and continued focus on improving screening and diagnosis of pediatric hypertension can help improve patient outcomes.
- National High Blood Pressure Education Program Working Group on High Blood Pressure in Children and Adolescents. The fourth report on the diagnosis, evaluation, and treatment of high blood pressure in children and adolescents. Pediatrics. 2004;114(2)(suppl 4th Report):555–576. PMID:15286277
- Flynn JT, Kaelber DC, Baker-Smith CM, et al. Subcommittee on Screening and Management of High Blood Pressure in Children. Clinical practice guideline for screening and management of high blood pressure in children and adolescents. Pediatrics. 2017;140(3):e20171904. doi:10.1542/peds.2017-1904 [CrossRef] PMID:28827377
- Lande MB, Kupferman JC. Pediatric hypertension: the year in review. Clin Pediatr (Phila). 2014;53(4):315–319. doi:10.1177/0009922813499968 [CrossRef] PMID:23960265
- Lauer RM, Clarke WR. Childhood risk factors for high adult blood pressure: the Muscatine Study. Pediatrics. 1989;84(4):633–641. PMID:2780125
- Wühl E, Trivelli A, Picca S, et al. ESCAPE Trial Group. Strict blood-pressure control and progression of renal failure in children. N Engl J Med. 2009;361(17):1639–1650. doi:10.1056/NEJMoa0902066 [CrossRef] PMID:19846849
- Peco-Anti A, Paripovi D. Renal hypertension and cardiovascular disorder in children with chronic kidney disease. Srp Arh Celok Lek. 2014;142(1–2):113–117. doi:10.2298/SARH1402113P [CrossRef] PMID:24684043
- American Academy of Pediatrics. Bright futures. Guidelines for health supervision of infants, children and adolescents. https://brightfutures.aap.org/Bright%20Futures%20Documents/BF4_Introduction.pdf. Accessed May 20, 2020.
- Miyashita Y, Hanevold C. Evaluation and management of stage 2 hypertension in pediatric patients. Curr Hypertens Rep. 2018;20(9):73. doi:10.1007/s11906-018-0873-z [CrossRef] PMID:29980866
- Rinke ML, Singh H, Brady TM, et al. Cluster randomized trial reducing missed elevated blood pressure in pediatric primary care: project RedDE. Pediatr Qual Saf. 2019;4(5):e187. doi:10.1097/pq9.0000000000000187 [CrossRef] PMID:31745503
- Rinke ML, Singh H, Heo M, et al. Diagnostic errors in primary care pediatrics: project RedDE. Acad Pediatr. 2018;18(2):220–227. doi:10.1016/j.acap.2017.08.005 [CrossRef] PMID:28804050
- Bijlsma MW, Blufpand HN, Kaspers GJ, Bökenkamp A. Why pediatricians fail to diagnose hypertension: a multicenter survey. J Pediatr. 2014;164(1):173–177.e7. doi:10.1016/j.jpeds.2013.08.066 [CrossRef] PMID:24120124
- Brady TM, Solomon BS, Neu AM, Siberry GK, Parekh RS. Patient-, provider-, and clinic-level predictors of unrecognized elevated blood pressure in children. Pediatrics. 2010;125(6):e1286–e1293. doi:10.1542/peds.2009-0555 [CrossRef] PMID:20439598
Indications to Check Blood Pressure More Frequently Than at the Annual Well-Child Visits
History of prematurity <32 weeks gestation or small for gestational age, very low birth weight, other neonatal complications requiring intensive care, umbilical artery line
Congenital heart disease (repaired or unrepaired)
Recurrent urinary tract infections, hematuria, or proteinuria
Known renal disease or urologic malformation
Family history of congenital renal disease
Malignancy or bone marrow transplant
Treatment with drugs known to raise blood pressure
Other systemic illnesses associated with hypertension (neurofibromatosis), tuberous sclerosis, sickle cell disease)
Evidence of increased intracranial pressure
Obesity or type 2 diabetes
|For children age 1–13 years
||For children older than age 13 years
|Normal BP: <90th percentile
||Normal BP: <120/<80 mm Hg
|Elevated BP: ≥90th percentile to 95th percentile or 120/80 mm Hg to <95th percentile (whichever is lower)
||Elevated BP: 120/<80 to 129/<80 mm Hg
|Stage 1 HTN: ≥95th percentile to <95th percentile + 12 mm Hg or 130/80 to 139/89 mm Hg
||Stage 1 HTN: 130/80 to 139/80 mm Hg
|Stage 2 HTN: ≥95th percentile + 12 mm Hg or ≥140/90 mm Hg (whichever is lower)
||Stage 2 HTN: ≥140/90 mm Hg