Pediatric and Adolescent Hypertension: A Multidisciplinary Call to Action

Heightened awareness and the rising prevalence of hypertension in children and adolescents has brought pediatric hypertension to the forefront of pediatric primary care.1,2 It has also made clear the need for public health programs and evidence-based lifestyle interventions to effectively prevent and manage this condition in youth.1,2 However, given that the ultimate aim of such efforts is to reduce rates of adult cardiovascular disease, how to best measure their success during childhood is unclear. In this perspective, we describe current challenges and gaps in research related to this dilemma while highlighting the need for multidisciplinary collaboration between pediatric primary care providers, researchers, public health practitioners, and hypertension experts to move toward effective prevention and management of this condition.A percentile-based definition is used for hypertension in children younger than 13 years because longitudinal outcome data linking blood pressure (BP) levels in childhood to cardiovascular events in adulthood are limited.2–5 Ample evidence associates childhood BP to markers of increased cardiovascular risk across the life course, but how these risks increase alongside BP is not well defined. In fact, recent evidence suggests that the detrimental effects of high BP in childhood can be detected at levels below what current guidelines define as hypertensive.3 Therefore, ambiguity remains regarding what level of reduction in BP is needed during youth to prevent long-term associated risks.3The American Academy of Pediatrics' Clinical Practice Guideline for Screening and Management of High Blood Pressure in Children and Adolescents, and the Clinical Practice Guideline for the Evaluation and Treatment of Children and adolescents with Obesity recommend regular BP screening in youth to support identification and management of pediatric hypertension.2,6 When recognized, the first line of treatment of hypertensive BPs in children is lifestyle modification, including dietary changes (decreased salt intake, increased fruit and vegetable consumption), increased physical activity, weight loss for those with an elevated body mass index (BMI), and stress reduction.2 The stated goal of these modifications is to reduce BP to the normal range.2,6 How often this reduction is achieved and sustained, as well as its long-term benefits, is unknown at this time. Furthermore, while normalization of BP is the ultimate goal, there may be smaller, more achievable reductions in BP that also meaningfully decrease long-term risk.Focus on and recognition of pediatric hypertension has increased, but further guidance related to effective nonpharmacologic management of the condition is needed. Public health programs and evidence-based lifestyle interventions hold promise in prevention and treatment of pediatric hypertension; however, there are important challenges and gaps in the current research that must be addressed to build this evidence base.First, although awareness of pediatric hypertension has increased, screening for and diagnosis of this condition remains low and is still not supported by consensus organizations.7 Put simply, a condition cannot be treated without first being recognized. Obtaining reliable BP measures can be challenging, as can interpreting children's BP measurements, because of the percentile-based definition used for younger children. Despite these challenges, it is critical that efforts to support reliable and regular BP measurement in pediatric primary care settings continue and systems, such as flagging of high BPs by electronic medical records, are in place to help primary care providers recognize abnormal values. In addition to accurate measurement, consistency in reporting is also needed. In research settings, BP can and is characterized in a variety of ways, including as a percentile, as mmHg, as a z-score, and as categories (normal, elevated, hypertensive). This variation in reporting of BP has already hindered our ability to conduct meta-analyses of longitudinal data.4 To effectively compare across studies and ultimately build an evidence base for the longitudinal impacts of pediatric hypertension and effective nonpharmacologic management, both accurate measurement and consistency in reporting of BP are needed.Second, when hypertension is recognized, guidance on effective management is needed. As previously noted, there are limited longitudinal outcome data linking BP and, therefore, BP reduction in children and adolescents to reduction of cardiovascular disease in adulthood.2–5 This evidence gap has resulted in uncertainty regarding what constitutes a clinically meaningful reduction in BP and has left programs and interventions focused on pediatric hypertension without a clear or common goal. As described above, the American Academy of Pediatrics' current guidelines recommend a return to the normal BP range as the goal of lifestyle intervention.2 Although we agree that this is the ultimate goal, such a reduction may not be achievable within the confines of investigational trials of lifestyle interventions nor through lifestyle interventions delivered during well-child visits, which may be limited by time and competing priorities (ie, addressing parents' concerns, completing necessary screenings, delivering vaccinations, etc.). Furthermore, guidance is not given for primary care providers as to how long to try to reach this goal of a return to normal with lifestyle interventions before moving onto pharmacologic management or referring to a specialist. Importantly, this use of return to normal as a binary measure may also mask positive effects of interventions that achieve smaller but perhaps still meaningful reductions in BP. Using the reduction achieved by antihypertensive drugs as a benchmark has also been suggested, as has the notion that any reduction in BP is desirable. Prospective studies and expert consensus on what constitutes a meaningful BP reduction beyond just a return to normal are needed.Lastly, there are limited evidence-based, nonpharmacologic, management options because research in which reduction of BP in childhood is the primary goal is lacking. Most current evidence on the impact of physical activity and dietary modifications on BP comes from obesity-focused interventions. There is clear opportunity for synergy between obesity and hypertension prevention and treatment efforts as decreasing BMI has been shown to lower BP.8 However, BP is only reported in a small subset of the abundant research on lifestyle-based treatment and prevention of obesity. To build a stronger evidence base, BP should be measured and reported in all programs and interventions targeting obesity. Importantly, however, this alone will not fill the gap related to hypertension management because primary pediatric hypertension can occur in the absence of elevated BMI. Therefore, interventional efforts focused specifically on reduction of BP in youth are also needed.Although longitudinal evidence linking specific BP level in youth to adult cardiovascular outcomes continues to increase, there is a current and pressing need to also support a growing evidence base of programs and interventions to prevent and manage pediatric hypertension. To do so, there is a need for expert consensus informed by current evidence to define what constitutes a clinically meaningful reduction in pediatric BP. It is important that such guidance comes from a collaborative effort across disciplines, including pediatric primary care providers, researchers who are designing and conducting interventional trials, public health practitioners who are implementing programs, and pediatric hypertension experts.We first call for heightened recognition of hypertension within pediatric primary care and continued efforts to support regular and accurate BP measurement in these settings. In tandem, we call for multidisciplinary expert consensus on what constitutes a meaningful reduction in BP beyond just a return to normal. Additionally, we call for the inclusion of BP as an outcome in obesity research, increased research efforts related to public health programs and evidence-based lifestyle interventions specifically aimed at decreasing BP in childhood, and consistency in how BP is reported in these efforts. Finally, we call for continued investment in long-term prospective studies linking specific levels of BP in childhood to adult cardiovascular outcomes.