Pediatric Hypertension: Provider Perspectives

School Nurse Practices Related to Blood Pressure Screening, and Identification and Monitoring of High Blood Pressures in Youth

Despite rising prevalence of high blood pressure among youth, literature on school nurses' practices related to youth blood pressure is limited. We aimed to describe school nurses' current practices related to blood pressure screening and identification and monitoring of high blood pressures. We conducted a web-based national survey of currently practicing school nurses and received 195 responses across 37 states. All participants reported having a blood pressure cuff, nearly all (98%) reported confidence measuring children's blood pressure, and 82% reported interest in doing more to support children's cardiovascular health. Blood pressure measurement by school nurses was common (73% reported "sometimes" or "often" and 25% reported "seldomly"). However, only 32% stated hypertension impacts their students and only 19% endorsed having enough time to complete all their necessary tasks. In describing school nurse's current practices related to youth blood pressure, we highlight opportunities for expanding this role and considerations for doing so.

Screening and Management of Pediatric High Blood Pressure-Challenges to Implementing the Clinical Practice Guideline

PURPOSE OF REVIEW

Elevated blood pressure (BP) and hypertension in childhood convey risk for hypertension and cardiovascular events in adulthood. Early recognition of abnormal BPs is key to preventing or lessening this risk. However, the process for making the diagnosis of hypertension is complex, and overall adherence to the 2017 American Academy of Pediatrics Clinical Practice Guidelines (CPG) is poor. We will review obstacles to adherence to the CPG and approaches designed to improve the diagnosis and management of hypertension in children.

RECENT FINDINGS

Baseline data from the multi-center quality improvement intervention, "Boosting Primary Care Awareness and Treatment of Hypertension" (BP-CATCH), demonstrate that childhood hypertension remains underdiagnosed. Other studies confirm a lack of compliance with the process outlined in the CPG. The provision of electronic prompts, coaching, and education results in modest improvements. The combination of embedded medical record tools and education seems to offer the most hope for improvement.

Perspectives of Primary Care Clinicians on the Diagnosis and Treatment of Pediatric Hypertension

The purpose of this study was to contextualize the challenges of diagnosing and managing pediatric hypertension (pHTN) in federally qualified health centers. We conducted a survey among primary care clinicians (N = 72) who treat children (3-17 years old) in a national network of health centers. Clinicians reported practices of blood pressure (BP) measurement, barriers to diagnosis and management of pHTN, and use of population health tools. Most clinicians (83%) used electronic devices to measure BP, only 49% used manual BP readings for follow-up measurements, and more than half measured BP at each encounter. The highest-rated barrier to pHTN management was lack of comfort with antihypertensive medications (71% of respondents). Few clinicians (10%) had used population health tools, but most (78%) indicated they would like to use them for pHTN. These results offer clinician-level insights regarding implementation of the pHTN guideline in pediatric primary care settings.

Prevalence and associated factors of hypertension among primary school children: A cross-sectional study in Kuching, Sarawak

Introduction

Hypertension is an emerging health concern among children owing to its increasing prevalence and association with obesity. However, hypertension screening is uncommon, and childhood hypertension-related data are limited. This cross-sectional study determined the prevalence and associated factors of hypertension among primary school children in Kuching, Sarawak.

Method

Standard procedures and validated equipment were used to measure blood pressure and anthropometric indicators. The body mass index (BMI)-for-age and waist-to-height ratio (WHtR) were calculated. Questionnaires were used to obtain family sociodemographic data and health history.

Results

A total of 1,314 children aged 6-12 years were enrolled, of whom 107 (8.1%) and 178 (13.5%) were hypertensive and pre-hypertensive, respectively. The chi-squared test indicated that hypertension was significantly associated with male sex (P<0.05), >1 standard deviation BMI-for-age (P<0.001), percentage of excess body fat (BF)(P<0.001), 5th to 95th height percentile (P<0.001), >90th excess waist circumference (WC) percentile (P<0.001), >90th WHtR percentile (P<0.001), clerical, service, sales and skilled parental work (P<0.05), excess weight (P<0.05) and cardiovascular disease (P<0.01). Multivariate logistic regression analysis showed that the percentage of excess BF [odds ratio (OR): 4.84, 95% confidence interval (CI): 2.01-11.66] and excess WC (OR: 2.33, 95% CI: 1.15-4.72) were significantly related to hypertension after adjusting for sex and age.

Conclusion

The prevalence of hypertension among the study population is higher than that among children worldwide. Childhood hypertension-related factors must be identified to aid in routine blood pressure screening, which is crucial for early detection and intervention to reduce future morbidity burden.

Lifestyle Interventions for Elevated Blood Pressure in Childhood-Approaches and Outcomes

PURPOSE OF REVIEW

The purpose of this review is to provide an overview of existing and emerging lifestyle treatments in the clinical management of primary elevated blood pressure and hypertension in pediatric patients. The authors hope to expand the knowledge base surrounding pediatric hypertension and update clinicians on best practices to improve outcomes.

RECENT FINDINGS

Elevated blood pressure is traditionally addressed with broad lifestyle recommendations such as limiting salt consumption and losing weight. This approach is not well adapted for pediatric patients. Novel and often underutilized approaches to the treatment of hypertension in pediatrics include psychological counseling for behavior modification, circadian nutrition, consistent use of interdisciplinary teams, manipulation of macronutrients, stress management, technology-infused interventions, and systemic changes to the food environment. Elevated blood pressure is a pervasive condition affecting cardiovascular disease and mortality risk. Increasingly, pediatric patients are presenting with elevated blood pressure with etiologies known to be affected by lifestyle behaviors. Weight management, dietary modifications, and daily physical activity are well-researched methods for improving individual blood pressure measurements. These strategies can sometimes be as effective as pharmacological interventions at lowering blood pressure. However, compliance with these individual recommendations is not consistent and has led to unsatisfactory results. There are emerging treatment trends that may provide non-traditional and more effective non-pharmacologic routes to blood pressure management in pediatric patients.

Prevalence of Secondary Hypertension in Otherwise Healthy Youths with a New Diagnosis of Hypertension: A Meta-Analysis

OBJECTIVE

To estimate the prevalence of secondary hypertension among otherwise healthy children with hypertension diagnosed in the outpatient setting.

STUDY DESIGN

The MEDLINE, PubMed Central, Embase, Web of Science, and Cochrane Library databases were systematically searched for observational studies reporting the prevalence of secondary hypertension in children who underwent evaluation for hypertension and had no known comorbidities associated with hypertension at the time of diagnosis. Two authors independently extracted the study-specific prevalence of secondary hypertension in children evaluated for hypertension. Prevalence estimates for secondary hypertension were pooled in a random-effects meta-analysis.

RESULTS

Nineteen prospective studies and 7 retrospective studies including 2575 children with hypertension were analyzed, with a median of 65 participants (range, 9-486) in each study. Studies conducted in primary care or school settings reported a lower prevalence of secondary hypertension (3.7%; 95% CI, 1.2%-7.2%) compared with studies conducted in referral clinics (20.1%; 95% CI, 11.5%-30.3%). When stratified by study setting, there were no significant subgroup differences according to study design, country, participant age range, hypertension definition, blood pressure device, or study quality. Although the studies applied different approaches to diagnosing secondary hypertension, diagnostic evaluations were at least as involved as the limited testing recommended by current guidelines.

CONCLUSIONS

The low prevalence of secondary hypertension among children with a new diagnosis of hypertension identified on screening reinforces clinical practice guidelines to avoid extensive testing in the primary care setting for secondary causes in most children with hypertension.

Paediatric hypertension for the primary care provider: What you need to know

The prevalence of hypertension has increased in the paediatric and adolescent populations, and is estimated between 1% and 2% in Canada. Paediatric and adolescent hypertension differs from adult hypertension in many ways, and primary care providers may not be up to date with current guidelines and recommendations. Recently, the American Academy of Pediatrics updated and published guidelines on the diagnosis, evaluation, and management of hypertension in children and adolescents. This paper summarizes these new guidelines in addition to the existing Canadian guidelines in a simple four-step approach, catered to a primary care setting, detailing the diagnosis, evaluation, workup, and management of hypertension in children and adolescents.

Under‐recognition of pediatric hypertension diagnosis: Examination of 1 year of visits to community health centers

Pediatric hypertension is associated with significant target organ damage in children and cardiovascular morbidity in adulthood. Appropriate diagnosis and management per guideline recommendations are inconsistent. In this study, we determined the proportion of missed diagnosis of hypertension and prehypertension and appropriate follow‐up in pediatric patients, stratified by sex, age, race/ethnicity, and weight status. Based on the electronic health record (EHR) data from eight federally qualified health centers, among 62,982 children aged 3 to 18 years, 6233 (10%) had at least one abnormal blood pressure (BP) measurement over twelve months. Among those children whose recorded BPs met the criteria for prehypertension (N = 6178), 14.6% had a diagnosis in the EHR. These children were more likely to be White and have obesity compared with children who met the criteria but were not diagnosed with prehypertension. Among those who met the criteria for hypertension (N = 55), 41.8% had a diagnosis of hypertension in the EHR. Being diagnosed with hypertension was not associated with any examined patient characteristics. Over eleven months, 2837 children had BP ≥ 95th percentile on ≥ 1 visit. Only 13% had guideline‐adherent follow‐up within 1 month and were more likely to be older, female, and of Hispanic ethnicity or “other” race. Over six months, 2902 children had BP ≥ 90th percentile on one visit. 41% had guideline‐adherent follow‐up within 6 months and were more likely to be older, of either White, Hispanic, Asian race, or Hispanic ethnicity. In a community‐based setting, pediatric hypertension and prehypertension were persistently underdiagnosed with low adherence to recommended follow‐up.

Pediatric Hypertension: Parent Perspectives

Clinical practice guidelines for diagnosis and management of pediatric hypertension have been available for decades. Yet, most cases of hypertension in children are undiagnosed. Provider and system-based factors, such as the complexity of diagnostic standards, and a failure among physicians to recognize the importance of hypertension in children, play a role in underdiagnosis. It is unclear, however, how patient and family behaviors impact the diagnosis and treatment of pediatric hypertension. We aimed to explore the perspectives of parents whose children have had multiple high blood pressure readings or have been diagnosed with hypertension to inform clinicians with areas for practice improvement. In a 2 site qualitative study, we interviewed parents of 15 children diagnosed with hypertension. Results from semi-structured interviews with parents revealed barriers to the diagnosis of pediatric hypertension, including uncertainty about the diagnosis and concerns around the accuracy of blood pressure measurements. Delay in diagnosis and lack of child engagement emerged as obstacles to the treatment of pediatric hypertension.

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.

Optimizing the implementation of a population panel management intervention in safety-net clinics for pediatric hypertension (The OpTIMISe-Pediatric Hypertension Study)

BACKGROUND

Though clinical practice guidelines are available, the diagnosis of pediatric hypertension (HTN) is often missed. Management may not follow guidelines due to the measurement challenges in children, complexity of interpreting youth blood pressure standards that are dependent on height, age, and sex, familiarity with diagnostic criteria, and variable comfort with management of pediatric HTN among providers. Evidence suggests that wide adoption and adherence to pediatric HTN guidelines would result in lower cardiovascular disease and kidney damage in adulthood. The proposed project will develop an implementation strategy package to increase adherence to clinical practice guidelines for pediatric HTN within safety-net community health centers (CHCs). The centerpiece of which is a provider-facing population panel management (PPM) tool and point-of-care clinical decision support (CDS). Prior research indicates that multiple discrete implementation strategies (e.g., stakeholder involvement, readiness planning, training, ongoing audit and feedback) are needed to institute practice- and provider-level adoption of such tools.

METHODS

Using participatory research methods involving stakeholders from a practice-based research network of CHCs, with input from scientific advisors, the project aims to (1) employ user-centered design methods to tailor an existing CDS tool for use at the point of care and optimize cohort management with a PPM tool to support adherence to the latest pediatric HTN guidelines, and (2) use a stakeholder-driven method for selecting implementation strategies that support tool adoption and increase guideline-adherent physician behaviors. Multilevel process evaluation using surveys and key informant interview data will assess the acceptability, adoption, appropriateness, cost, and feasibility of the PPM tool and its multicomponent implementation strategy package. Usability testing will be conducted with the PPM tool to iteratively refine features and ensure proper functionality.

DISCUSSION

The proposed research has the potential to improve identification, diagnosis, and management of HTN in primary care settings for high-risk youth by assisting healthcare providers in implementing the American Academy of Pediatrics' 2017 guidelines using an EHR-integrated PPM tool with CDS. Should the strategy package for PPM tool adoption be successful for pediatric HTN, findings will be translatable to other settings and PPM of other chronic cardiovascular conditions affecting overall population health.

Pediatric hypertension: diagnostic patterns derived from electronic health records

Background

Pediatric hypertension is a serious problem associated with target organ damage in children and an increased risk for adult hypertension. African-American and Latino children are disproportionately affected. Unfortunately, due to a variety of factors, including the complexity of blood pressure (BP) standards, pediatric hypertension is undiagnosed in the majority of cases. We sought to identify factors associated with correct diagnosis and to better understand diagnosis of hypertension by studying the diagnostic paths of a small number of children.

Methods

Data were extracted from electronic health records (EHRs) of children who met criteria for hypertension. Logistic regression was used to identify factors associated with correct diagnosis. Diagnostic paths for 20 diagnosed children were extracted through chart review and analyzed.

Results

Among 1478 hypertensive children, only 85 were diagnosed (6.1%). Age ≥12 compared to age ≤6 was associated with correct diagnosis [odds ratio (OR) of 1.96, 95% confidence interval (CI) (1.16, 3.32)]. Diagnostic paths revealed that primary care providers (PCPs) make the diagnosis based on multiple readings over time and order laboratory tests appropriately.

Conclusions

Hypertension is missed in a large proportion of all children. Effective, systematic approaches to diagnosis are necessary.

The Use of Electronic Health Records to Identify Children with Elevated Blood Pressure and Hypertension

Elevated blood pressures often go unrecognized in pediatric patients, potentially putting children and adolescents at risk for the sequelae of untreated hypertension. This may be partially due to the complexity involved in diagnosing elevated pediatric blood pressures, which demands a high cognitive workload from providers. Tools built into electronic health records have the potential to alleviate this workload, and studies investigating these tools confirm they show promise in improving elevated blood pressure recognition. However, the current tools are not perfect, and determining the optimal design and implementation of future iterations requires further study. The proper integration of patient-generated blood pressure readings, such as those obtained during ambulatory blood pressure monitors, also requires careful consideration.