How Pharmacists Can Help Parents Navigate Conflicting Information About Pediatric Hypertension Screening
Hypertension has earned a place on the list of adult chronic diseases that are now being diagnosed in children. The problem is that experts are still refining some vital details, like the extent to which high blood pressure at an early age predicts adult disease and the best approach to pediatric hypertension screening.
Another concern with blood pressure screening in children is the risk of false positives, which may lead to higher medical costs and anxiety or confusion in parents and children. Pharmacists can help solve these concerns by offering BP screenings and counseling, but even if you don’t take that step, be prepared to field questions from parents.
Prevalence and Impact of Hypertension in Children
Pediatric hypertension is defined as blood pressure (BP) that’s higher than 95 percent of children who are the same age, height, and sex.1 Prehypertension may be diagnosed when a child’s BP is above the 90th percentile and below the 95th. Current prevalence rates fall between 2 to 5 percent, but it’s hard to know if these estimates are accurate since questions still remain about how consistently children are screened and diagnosed.
A study published in the December 2016 issue of Pediatrics reported that hypertension and prehypertension in children often goes undiagnosed.2 After evaluating electronic health records on more than 1.2 million pediatric patients from 196 ambulatory clinics across 27 states, researchers narrowed the number of subjects down to about 400,000 patients aged 3 to 18 who had three or more visits with BP measurements. They found that guidelines for diagnosis and medical management aren’t routinely followed:
- 3.3 percent met criteria for hypertension – of these, 23 percent were diagnosed
- 10 percent met criteria for prehypertension – of these, 10 percent were diagnosed
- Out of 2,813 patients persistently hypertensive for a year – only 6 percent were prescribed antihypertensive medication:
- 35 percent were prescribed angiotensin-converting enzyme inhibitors/angiotensin receptive blockers
- 22 percent were prescribed diuretics
- 17 percent were prescribed calcium channel blockers
- 10 percent were prescribed beta-blockers
Several studies suggest that high BP in childhood predicts hypertension in adulthood. For example, the Fels Longitudinal Study published in June 2013 found that systolic BP between the 50th and 95th percentiles predicted high BP in adulthood.3 However, the paucity of data means waiting for future longitudinal studies to define the association. In the meantime, research has confirmed markers of target organ injury are evident in pediatric hypertension, especially left ventricular hypertrophy.
Current Recommendations for Pediatric Hypertension Screening
The American Academy of Pediatrics recommends that all children have their BP checked annually, beginning at the age of 3 years.4 Most sources suggest the same or modify it slightly to suggest screening at each ambulatory visit. As it turns out, virtually all doctors—97 percent—measure BP at well-child visits, according to a September 2016 study in the Journal of Clinical Hypertension.5 That leaves another important question—what happens when BP is high after an initial reading?
In 2004, the US Fourth Report recommended that the most accurate diagnosis was achieved when elevated BP was measured on at least three occasions. Over the years, experts have debated whether three measurements were really needed, but research published in the January 2017 issue of Hypertension Research confirmed that the prevalence of BP decreases significantly over multiple visits, from 12 percent at the first visit down to about 3 percent on visit three.6
Even though most doctors measure BP, the September 2016 study also reported that only 20.8 percent of children with elevated BP get a repeat measurement within one month and a mere 15 percent have their BP rechecked. Additionally, 60 percent didn’t receive any further intervention. The lack of multiple readings and follow-up indicates a serious gap in the assessment and diagnosis of pediatric hypertension—it also points to potential shortcomings in studies that draw conclusions based on a single BP reading.
Information to Consider When Counseling Parents
The U.S. Preventive Services Task Force (USPSTF) doesn’t offer a recommendation about screening for hypertension in children, saying that the evidence is either lacking or conflicting and that the balance of benefits and harms can’t be determined.7 The risk of false positive readings is one of the harms cited by the USPSTF, which enforces the concept of getting three BP measurements, but also raises concern about higher health costs for ongoing testing and the potential for unnecessary anxiety or confusion in parents. Since they’re likely to turn to their community pharmacist, be ready to deal with issues such as:
- Lack of information – Parents may not know much about hypertension in general and even if they are familiar with the disease, they may have questions about its cause and health implications in children. Be prepared to offer basic education.
- Medication management – If medications were prescribed, emphasize the importance of medication adherence. Talk with them about options like liquid forms and added flavoring that make it easier for children to take medications.
- What to do next – It’s not hard to imagine a scenario where an otherwise healthy child has a mild to moderately high BP, the doctor decides to wait for their next well-child visit to get a second reading, but doesn’t give a full explanation to the parent about why that’s acceptable because time is short. The parent may not know whether to be concerned or what to do while waiting for the next BP reading. This is a good time to tell them that diet and exercise are always first-line treatment options—and this approach doesn’t cause any harm should it turn out to be a false positive. Suggest that they:
- Adjust their child’s diet if needed – Remind them to cut out saturated fats and salt, while boosting consumption of fruits, vegetables, and fiber. Frozen and canned fruits and vegetables are perfectly acceptable, as long as they’re salt-free and packed in natural juices. They should offer high-potassium foods like raisins, tomatoes, bananas, oranges, orange juice, beans, and dark leafy greens.
- Increase activity – Parents should engage their kids in 30 to 60 minutes of physical activity daily.
- Lose weight if necessary – Obese children are three times more likely to develop hypertension—encourage parents to monitor caloric intake and to eliminate sweets and beverages with added sugar.
Monitor Blood Pressure in the Pharmacy to Improve Children’s Health and Well-Being
Since multiple measurements are such an important tool, you can reassure parents by offering free BP monitoring in your pharmacy. After explaining the value of obtaining several BP readings, ask for permission to communicate with their physician and coordinate a plan of action. Taking this step does more than calm parent anxiety; it also creates a community activity that brings attention to your pharmacy and establishes your willingness to work with patients—and that’s good for business.
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- “Pediatric Hypertension,” July 2015, http://emedicine.medscape.com/article/889877-overview ↩
- “Diagnosis and Medication Treatment of Pediatric Hypertension: A Retrospective Cohort Study,” December 2016, https://www.ncbi.nlm.nih.gov/pubmed/27940711 ↩
- “The Predictive Value of Childhood Blood Pressure Values for Adult Elevated Blood Pressure,” June 2013, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3752649/ ↩
- “High Blood Pressure in Children,” November 2015, https://www.healthychildren.org/English/health-issues/conditions/heart/Pages/High-Blood-Pressure-in-Children.aspx ↩
- “Pediatric Hypertension: Are Pediatricians Following Guidelines?” September 2016, http://onlinelibrary.wiley.com/doi/10.1111/jch.12915/full ↩
- “Definition of Pediatric Hypertension: Are Blood Pressure Measurements on Three Separate Occasions Necessary?” January 2017, https://www.ncbi.nlm.nih.gov/pubmed/28077857 ↩
- “Screening for Primary Hypertension in Children and Adolescents: Recommendation Statement,” February 2015, http://www.aafp.org/afp/2015/0215/od1.html ↩