U.S. Preventive Services Task Force Recommendation and Pediatric Hypertension Screening: Dereliction of Duty or Call to Arms?

As medicine has become increasingly complex, there is a growing need to promote the use of strategies that yield the greatest improvements in health outcomes and that are cost-effective. One method to achieve this objective is to publish guidelines for clinical practice based on a review and grading of the existing literature. Guidelines can address utilization of newly developed, costly, high-risk therapies or simple diagnostic tests that are considered standard of care. The National Heart Lung and Blood Institute and Kidney Disease Improving Global Outcomes have been leading forces in this movement and have published updated guidelines every few years on the gamut of problems encountered in nephrology, including hypertension.1 Most pediatricians would assert that measurement of blood pressure (BP) should be incorporated into the care of all children and adolescents. They know that the American Academy of Pediatrics has recommended that routine measurement of BP should be done at well toddler, children, and teen visits. Pediatric nephrologists have been more vocal in their advocacy for routine measurement of BP at all encounters because hypertension can be a sign of significant underlying disease and is often asymptomatic.2 There is no doubt that BP measurement per se is a safe, readily accessible, and low-cost procedure. One might ask whether a practice guideline is needed at all. The U.S. Preventive Services Task Force (USPSTF) has stepped into this seemingly trivial and self-evident area of care and has concluded that “current evidence is insufficient to assess the balance of benefits and harms” of screening for high BP in asymptomatic children to prevent heart disease. They assert, based on the literature, that childhood readings do not predict hypertension in later life, and that there is no proven benefit of treatments designed to lower BP in the pediatric years.3 The clear implication is that BP should not be measured routinely in otherwise healthy children and adolescents. As might be expected, this recommendation has been met with strong opposition among pediatric nephrologists. The American Society of Pediatric Nephrology issued a press release that expressed concern that the USPSTF position will discourage pediatricians from measuring BP and undermine efforts to identify hypertension, especially in those children with disease who are asymptomatic. We are three pediatric nephrologists who think the USPSTF may have done our subspecialty a great service and here is why. The USPSTF report was anticipated in a review by Chiolero and colleagues published earlier this year.4 Despite the good intentions of most pediatricians and family practitioners, the majority of children do not have their BP checked at routine ambulatory visits and only 80% of obese adolescents attending preventive care visits have their BP measured.5 Even in pediatric hypertension clinics, the majority of patients have no identifiable underlying secondary disease.6 Even if there is an underlying cause of hypertension, there is usually no immediate threat to health in otherwise well children. When elevated BP is a medical emergency, there are usually concomitant symptoms indicating the presence of a systemic cause for the hypertension. Malignant hypertension with the risk of sudden deterioration in cardiac or renal function is distinctly uncommon in children.7 This suggests that there is little risk of a policy that advocates deferring routine measurement of BP in asymptomatic children. Examining the issue from an economic perspective, the measurement of BP is cost-free when performed as part of the standard physical examination. However, this overlooks the costs involved in the evaluation of a pediatric patient with newly identified high BP that can include consultations with a nephrologist and/or cardiologist, nutritional assessment, and an array of blood tests and imaging studies. Furthermore, there are the costs of treatment, minimal for lifestyle changes and substantive for drug-based therapy. Recognizing all of this, it is clear that practice guidelines that help balance the benefits and risks of a procedure or a treatment are valuable, even for a seemingly innocuous test such as routine measurement of BP in children. The pressing questions then become, has the USPSTF abdicated its responsibility to promote cost-effective procedures that will improve the health of children? Will it undermine efforts to educate doctors and laypeople about the importance of hypertension and lead to increased prevalence of cardiovascular disease in adulthood? It would be premature to answer these questions affirmatively based on what we know about the current standard of care, the causes of hypertension in childhood, and the public health ramifications of hypertension in pediatric patients. Pediatric hypertension experts recognize that the majority of BP readings performed in the community are inaccurate, resulting in a high false-positive rate for the diagnosis of hypertension. This leads to expenditures on tests that neither yield a diagnosis nor impact patient management. The prevalence of secondary hypertension in children remains low and there is no evidence to support a rising incidence rate. Historically, these patients were identified because they developed symptoms or physical findings that pointed to the value of measuring the BP. The dramatic rise in hypertension associated with obesity and the metabolic syndrome has no impact on the occurrence of secondary hypertension. Peeling away the thick layer of children with weight-related hypertension, one can question whether routine BP measurements in all children at all visits will enhance the rate of diagnosis of secondary hypertension and improve the outcomes in this markedly smaller subgroup of patients. That still begs the question, what should be done for all of those children who have been found to have high BP in association with overweight and obesity? Does routine BP measurement assist in their care and improve outcomes? There is a lack of enthusiasm to initiate drug therapy in children with primary hypertension, especially in those with increased body mass index. Most parents are reluctant to embark on an indefinite course of antihypertensive therapy for their child. A reasonable approach might be to view all of these children as being at risk for developing hypertension. Instead of emphasizing BP measurements and accurate delineation of hypertension status, we could advance global strategies to reduce weight, increase physical activity, and foster healthy lifestyle choices that will correct obesity and, in all likelihood, restore normal BP in those in whom it is elevated. In fact, Chiolero and colleagues demonstrated that this was the most cost-effective strategy to treat pediatric hypertension.4 Even for the naysayers who question whether the public health measures outlined above will successfully reduce BP on a population basis, the burden of proof remains on those who advocate drug therapy. The efficacy and safety of this management approach in terms of long-term prevention of cardiovascular morbidity and death remains to be proven. There has been a rush to judgment and condemnation of the USPSTF report as being a dereliction in the duty to provide optimal care to children. We suggest that the USPSTF has provided a service to the community by motivating us to rethink how we approach the diagnosis of hypertension in asymptomatic children. It highlights the gaps in our knowledge and challenges us to work together as a community to gather better data about long-term consequences of elevated BP in children. It should encourage us to take advantage of new technologies such as the electronic health record to define the trajectory of BP from childhood into young adulthood and correlate this with improved collection of clinically relevant health outcomes. It represents a much needed call to arms to all specialists who treat hypertension in children to work closely with patients, their families, and other healthcare professionals to educate them on the implications of high BP and to devise approaches for detection, diagnosis, and treatment that meet the needs of our patients during childhood and later life. All pediatricians need to accept the challenge. The authors have no financial relationships relevant to this article to disclose. No funding was secured for this study. Tiffany Lo assisted in the literature review, reviewed and revised the manuscript, and approved the final manuscript as submitted. Dr Laura Malaga-Dieguez reviewed and revised the manuscript and approved the final manuscript as submitted. Dr Howard Trachtman conceptualized and designed the manuscript, drafted the initial manuscript, and approved the final manuscript as submitted.