Performance of blood pressure-to-height ratio as a screening tool for elevated blood pressure in pediatric population: a systematic meta-analysis

A proposal to simplify the definition of pediatric hypertension: bridging the gap between perception and action

BACKGROUND

The importance of routine hypertension screening in children and adolescents is now well recognized. However, it is often undiagnosed in clinical practice, partly due to the reliance on a complex blood pressure (BP) percentile-based table with hundreds of cutoffs by age, sex, and height.

MAIN TEXT

Many studies have explored simplified tools for screening hypertension in children and adolescents, such as simplified formulas, simplified BP tables by age and sex group, by age group, or by height group, and the BP to height ratio. Nevertheless, validation studies have demonstrated that these simplified tools are prone to yielding many false-positive cases or remain inconvenient to use in primary pediatric care settings and large-scale screening surveys. To address this issue, we propose adopting static BP cutoffs of 120/80 mmHg for children aged 6-12 years and 130/80 mmHg for adolescents aged 13-17 years to simplify the definition of hypertension. Our proposed static BP cutoffs have shown comparable performance to the complex BP percentile-based table in predicting subclinical cardiovascular damage in both childhood and adulthood.

CONCLUSIONS

We recommend using static BP cutoffs (120/80 mmHg for children and 130/80 mmHg for adolescents) to facilitate the screening of pediatric hypertension in clinical practice, thereby bridging the gap between perception and action.

Sex differences in the Buffalo Concussion Treadmill Test in adolescents with acute sport-related concussion

OBJECTIVES

The Buffalo Concussion Treadmill Test (BCTT) is a safe and validated tool to assess exercise tolerance after sport-related concussion (SRC). Sex differences may affect the interpretation of this systematic exertion test in the concussed population, which is important for clinicians. The purpose of this study was to examine sex differences in BCTT performance in adolescents with acute SRC.

DESIGN

Prospective cohort.

METHODS

Male (n = 103, 15.3 ± 2 years) and female (n = 87, 15.1 ± 2 years) adolescents with SRC performed the BCTT within 10 days of injury. Heart rate (HR), HR threshold (HRt), Delta HR (difference between resting HR and HRt), symptom severity on Visual Analog Scale (VAS) and symptoms exacerbated on the BCTT were collected and compared.

RESULTS

Males had lower resting HR (M: 70.9 ± 12 vs F: 75.7 ± 13 bpm, p < 0.01) and reached a lower HRt than females (M: 134.7 ± 23 vs F: 141.5 ± 25 bpm, p = 0.05). Sexes did not differ on Delta HR (M: 63.8 ± 26 vs F: 65.9 ± 24 bpm, p = 0.57), total treadmill time (M: 9.3 ± 5 vs F: 8.4 ± 4 min, p = 0.20), maximum VAS (M: 5.0 ± 2 vs F: 5.4 ± 2, p = 0.18) or incidence of a change in VAS (M: 91% vs F: 94%, p = 0.43) on the BCTT.

CONCLUSIONS

Although males may reach symptom exacerbation at a slightly lower mean HRt than females on the BCTT within 10 days of SRC, the BCTT provides comparable information and both sexes reach symptom exacerbation at similar Delta HR.

Blood Pressure in Childhood and Adolescence

Elevated blood pressure (BP) and hypertension commonly occur in children and adolescents and increase the risk of cardiovascular disease in adulthood. The purpose of this review is to summarize recent research in pediatric hypertension including changes in defining hypertension, BP measurement techniques, hypertension epidemiology, risk factors, treatment, and BP-related target organ damage. Defining pediatric hypertension using the 2017 American Academy of Pediatrics' updated Clinical Practice Guideline resulted in a larger proportion of children being classified as having elevated BP or hypertension compared with prior guidelines. Trends in the distribution of BP among US children and adolescents suggest that BP levels and the prevalence of hypertension may have increased from 2011-2014 to 2015-2018. Factors including a family history of hypertension, obesity, minority race/ethnicity, physical inactivity, high dietary intake of sodium, and poor sleep quality are associated with an increased prevalence of elevated BP and hypertension. Evidence of a linear relationship between systolic BP and target organ damage indicates that BP levels currently considered normal could increase the risk of target organ damage in childhood. Lifestyle changes, such as adhering to the Dietary Approaches to Stop Hypertension diet, are a central component of effectively reducing BP and have been shown to reduce target organ damage. Pharmacologic treatment using angiotensin-converting enzyme inhibitors and angiotensin receptor blockers is an effective and safe method for reducing BP among children with uncontrolled BP after implementing lifestyle changes. Research gaps in the prevention, detection, classification, and treatment of hypertension in children demonstrate opportunities for future study.

Are Body Composition Parameters Better than Conventional Anthropometric Measures in Predicting Pediatric Hypertension?

Body composition (BC) parameters are associated with cardiometabolic diseases in children; however, the importance of BC parameters for predicting pediatric hypertension is inconclusive. This cross-sectional study aimed to compare the difference in predictive values of BC parameters and conventional anthropometric measures for pediatric hypertension in school-aged children. A total of 340 children (177 girls and 163 boys) with a mean age of 8.8 ± 1.7 years and mean body mass index (BMI) z-score of 0.50 ± 1.24 were enrolled (102 hypertensive children and 238 normotensive children). Significantly higher values of anthropometric measures (BMI, BMI z-score, BMI percentile, waist-to-height ratio) and BC parameters (body-fat percentage, muscle weight, fat mass, fat-free mass) were observed among the hypertensive subgroup compared to their normotensive counterparts. A prediction model combining fat mass ≥ 3.65 kg and fat-free mass ≥ 34.65 kg (area under the receiver operating characteristic curve = 0.688; sensitivity = 66.7%; specificity = 89.9%) performed better than BMI alone (area under the receiver operating characteristic curve = 0.649; sensitivity = 55.9%; specificity = 73.9%) in predicting hypertension. In conclusion, BC parameters are better than anthropometric measures in predicting pediatric hypertension. BC measuring is a reasonable approach for risk stratification in pediatric hypertension.

Performance of modified blood pressure-to-height ratio for diagnosis of hypertension in children: The CASPIAN-V study

This study aimed to evaluate the accuracy and performance of modified blood pressure-to-height ratio (MBPHR) for identifying high blood pressure (HBP) in a large population of children. This multicentric cross-sectional study was conducted on a nationally representative sample of 7349 Iranian students aged 7-12 years living in 30 provinces in Iran. High systolic blood pressure and diastolic blood pressure were defined according to the 2017 American Academy of Pediatrics (AAP) guidelines. The BP-to height ratio (BPHR) was calculated as BP (mmHg)/height (cm), MBPHR3 as BP (mmHg)/(height (cm) + 3 (13-age)), and MBPHR7 as BP (mmHg)/(height (cm) + 7 (13-age). The receiver-operating characteristic curve analysis was used to evaluate the performance of these three ratios for identification of HBP in children compared to the 2017 AAP guidelines as the gold standard. Mean age of participants was 12.29 ± 3.15 years and 3736 (50.8%) were girls. The prevalence of HBP was 11.9% (11.5% in boys, 12.3% in girls). The area under the curve (AUC) was higher for MSBPHR3/MDBPHR3 (0.97/0.98) than MSBPHR7/MDBPHR7 (0.96/0.97) and SBPHR/DBPHR (0.96/0.95) for identifying high Systolic and diastolic BP. The optimal cut-off points for MSBPHR3/MDBPH, MSBPHR7/MDBPHR7, and SBPHR/DBPHR were 0.76/0.50, 0.69/0.46, and 0.81/0.52 respectively. Negative predictive value was nearly perfect for three ratios (≥98%). Positive predictive value was higher for MBPHR3 (52.7%) than MBPHR7 (51.0%) and BPHR (39.8%). Overall, MBPHR3 had better performance than MBPHR7 and BPHR for identification of HBP in Iranian children and it may improve early hypertension recognition and control in primary screening.

The challenge of simplifying blood pressure screening in children and adolescents

Simplified methods of blood pressure screening could facilitate the clinical routine of the primary care physicians and may increase adherence to pediatric hypertension guidelines. Blood-pressure-to-height ratios are appealing for the simplicity of data needed to evaluate a child's blood pressure status, including only office blood pressure values and height. In several epidemiological studies around the world blood-pressure-to-height ratios showed good predictive power in identifying children with high blood pressure in terms of area under the curve and sensitivity compared to the gold standard National High Blood Pressure Education Program blood pressure tables, but low positive predictive values meaning a high rate of false-positive cases and possibly increased subsequent work load for primary physicians. Finally, blood-pressure-to height ratios seem to be dependent to age, sex, and weight status. In conclusion, blood-pressure-to-height ratios need to be further improved and validated in different pediatric populations before routine clinical use.

Using blood pressure height index to define hypertension among secondary school adolescents in southwestern Uganda

Hypertension is the number one risk factor for cardiovascular diseases worldwide and yet its diagnosis among adolescents, based on blood pressure percentiles which are age, height, and sex-specific, is complex. Our study intended to determine the suitability of blood pressure height index in defining adolescent hypertension among secondary school adolescents aged 12-17 years in Mbarara municipality, southwestern Uganda. Our study used data of 485 secondary school adolescents of which 173 were boys. Receiver operating characteristic curve analysis was performed to assess the performance of systolic blood pressure height index (SBPHI) and diastolic blood pressure height index (DBPHI) for screening for adolescent prehypertension and hypertension. The optimal systolic/diastolic thresholds for defining prehypertension were 0.70/0.43 mmHg/cm in boys and 0.76/0.43 in girls. The corresponding values for hypertension were 0.78/0.43 and 0.77/0.48 mmHg/cm, respectively. The negative predictive values were much higher (all ≥ 95%) for prehypertension and hypertension, while the positive predictive value was 100% for hypertension in both sexes. In conclusion, Blood pressure height index is simple and accurate for screening for prehypertension and hypertension in adolescents aged 12-17 years hence can be used for early screening of adolescents at high risk of hypertension but not its diagnosis.

Using height-corrected definition of metabolic syndrome in children and adolescents

Metabolic syndrome (MS) is common among children and adolescents. Age- and gender-specific references or age-, gender- and height-specific references were used in pediatric MS definitions. More recently, an increasing number of studies documented that the ratio of waist circumference (WC) to height (WHtR) and blood pressure to height (BPHR) were easy anthropometric indexes for detection of obesity and hypertension in children and adolescents. For these reasons, height-corrected MS definition was proposed. WHtR and BPHR were used as alternatives to WC and BP in the definition of MS. In the present review, we discuss the possibility of the height-corrected MS definition for identifying MS in children.

A simple table based on height to assess elevated and high blood pressure in children

The 2017 American Academy of Pediatrics (AAP) guideline for assessing "elevated blood pressure (BP) (90^th BP percentile)" and "high BP (95^th BP percentile)" includes a large number of BP cut-offs based on sex, age and height, which makes it cumbersome to use in clinical practice. We developed and evaluated the performance of a simple table based on a child's height only to assess elevated and high BP in children compared to the reference AAP guideline based on sex, age and height. Data came from 6816 children aged 8-12 years from the U.S. National Health and Nutrition Examination Survey (NHANES) 1999-2016 and 3145 participants aged 5-12 years from NHANES III (1988-1994). Compared to the reference AAP guideline, the simple table had high values of AUC (0.96/0.91), sensitivity (92.7%/83.2%), specificity (99.0%/99.4%), PPV (92.6%/89.3%), NPV (99.0%/99.0%), and Kappa coefficient (0.92/0.85) for screening elevated/high BP when applied to NHANES, and values were similarly high when applied to NHANES III. These findings show that the simple table based on height only performed nearly as well as the reference 2017 AAP guideline based on sex, age and height for assessing elevated and high BP in U.S. children. This simple table may be a useful screening tool to assess high BP in children aged 5-12 years, particularly in a context of mass screening programs.

Performance of User-Friendly Screening Tools for Elevated Blood Pressure in Children

CONTEXT

Hypertension is frequently undiagnosed in children. Several methods have been developed to simplify screening for elevated blood pressure (BP) in children.

OBJECTIVE

to assess the performance of different screening tools in identifying elevated BP in the pediatric population.

DATA SOURCES

Data sources such as PubMed, Embase, Web of Science, Cochrane, and Scopus were searched up to March 2016.

STUDY SELECTION

Studies providing measures of diagnostic performance of screening tools and that used age-, sex-, and height-specific BP percentile as the reference standard were included.

DATA EXTRACTION

Data regarding the population, screening tools used to define elevated BP, and diagnostic criteria of BP were extracted. Available data on true-positive, false-positive, true-negative, and false-negative results were also extracted to construct a 2 × 2 contingency table.

RESULTS

A total of 16 eligible studies that evaluated 366 321 children aged 3 to 18 years were included in the meta-analysis. Nine screening tools were included in this study, in which the BP-to-height ratio, the modified BP-to-height ratio, and tables based on age categories had the highest sensitivities (97-98%) but moderate specificities (71-89%).

LIMITATIONS

Limitations included that BP measurements in most studies were based on 1 visit only and there was heterogeneity between the studies.

CONCLUSIONS

Several user-friendly screening tools could improve the screening of elevated BP in the pediatric population.

Blood pressure-to-height ratio as a screening indicator of elevated blood pressure among children and adolescents in Chongqing, China

We aimed to evaluate the performance of blood pressure-to-height ratio (BPHR) and establish their optimal thresholds for elevated blood pressure (BP) among children aged 6 to 17 years in Chongqing, China. Data were collected from 11 029 children and adolescents aged 6-17 years in 12 schools in Chongqing according to multistage stratified cluster sampling method. The gold standard for elevated BP was defined as systolic blood pressure (SBP) and/or diastolic blood pressure (DBP) ⩾95th percentile for gender, age and height. The diagnostic performance of systolic BPHR (SBPHR) and diastolic BPHR (DBPHR) to screen for elevated BP was evaluated through receiver-operating characteristic curves (including the area under the curve (AUC) and its 95% confidence interval, sensitivity and specificity). The prevalence of elevated BP in children and adolescents in Chongqing was 10.36% by SBP and/or DBP ⩾95th percentile for gender, age and height. The optimal thresholds of SBPHR/DBPHR for identifying elevated BP were 0.86/0.58 for boys and 0.85/0.57 for girls among children aged 6 to 8 years, 0.81/0.53 for boys and 0.80/0.52 for girls among children aged 9 to 11 years and 0.71/0.45 for boys and 0.72/0.47 for girls among adolescents aged 12-17 years, respectively. Across gender and the specified age groups, AUC ranged from 0.82 to 0.88, sensitivity were above 0.94 and the specificities were over 0.7. The positive predictive values ranged from 0.30 to 0.38 and the negative predictive values were ⩾0.99. BPHR, with uniform values across broad age groups (6-8, 9-11 and 12-17 years) for boys and for girls is a simple indicator to screen elevated BP in children and adolescents in Chongqing.