Action Points Note that the American Academy of Pediatrics has issued new guidelines on blood pressure screening and management. 
 
 Broadly, these guidelines harmonize with changes made in adult practice, such as eliminating the term "prehypertension" and replacing it with "elevated blood pressure." 
 
 The American Academy of Pediatrics today issued a clinical practice guideline for screening and management of high blood pressure in children and adolescents, with new wording to draw attention to lifestyle factors as keys to prevention and treatment. 
 
 Although the prevalence of hypertension has plateaued in recent years, 3.5% of all youth have the condition and elevated blood pressure readings often go undetected and untreated, said David Kaelber, MD, MPH, FAAP, of the Center for Health Care Research and Policy, and colleagues on the AAP Subcommittee on Screening and Management of High Blood Pressure in Children. 
 
 Published in Pediatrics, the report is intended to help improve patient diagnoses and outcomes, while reducing unnecessary and costly medical interventions. It follows the most recent set of guidelines which were issued in 2004 by the National Heart, Lung, and Blood Institute and is endorsed by the American Heart Association. 
 
 "If there is diagnosis of hypertension, there are many ways we can treat it ... but because the symptoms are silent, the condition is often overlooked," said Kaelber. "These guidelines offer a renewed opportunity for pediatricians to identify and address this important – and often unrecognized – chronic disease in our patients." 
 
 Stephen R. Daniels, MD, PhD, of University of Colorado School of Medicine, who also worked on the report, noted that it offers an up-to-date review of the literature on high blood pressure in pediatric patients. 
 
 "It differs from previous reports in that it provides a simpler approach to identification of high blood pressure for primary care providers and it seeks to provide better harmonization between the pediatric and adult approach to evaluation and treatment of high blood pressure," he explained to MedPage Today. 
 
 The AAP report replaces the term "prehypertension" with "elevated blood pressure" in order to be consistent with guidelines from the American Heart Association and American College of Cardiology. 
 
 The authors noted that the new terminology better conveys the importance of lifestyle measures -- such as dietary approaches to stop hypertension (DASH), physical activity, weight loss, and stress reduction -- to prevent the development of hypertension. 
 
 "The first-line treatment remains lifestyle changes, as there is a high correlation between hypertension and obesity," they stated. 
 
 In hypertensive children and adolescents who fail lifestyle modifications, clinicians should initiate pharmacologic treatment with an ACE inhibitor, angiotensin receptor blocker, long-acting calcium channel blocker, or thiazide diuretic. 
 
 While previous guidelines included tables with blood pressure measurements in children and adolescents who are overweight or obese -- a condition that is likely to increase blood pressure -- the new report focuses on normal-weight children. 
 
 The authors concluded that oscillometric devices should be used for blood pressure screening in children and adolescents, specifically a device that has been validated in the pediatric age group. If elevated blood pressure is suspected on the basis of oscillometric readings, confirmatory measurements should be obtained by auscultation. 
 
 The report also stated that routine blood pressure measurements should be performed only at annual preventive care visits. Best practices for blood pressure measurement include: 
 
 The child should be seated in a quiet room for 3–5 minutes before measurement with back supported and feet uncrossed on the floor. 
 
 Blood pressure should be measured in the right arm for consistency with arm at heart level and uncovered above the cuff. The patient and observer should not speak while the measurement is being taken. 
 
 Use the correct cuff size: the bladder length should be 80%–100% of the circumference of the arm and the width should be at least 40%. 
 
 Patients should be in the prone position when blood pressure is measured in the legs. An appropriately sized cuff should be placed mid-thigh and the stethoscope placed over the popliteal artery. 
 
 Other recommendations for pediatricians include: 
 
 Follow a simpler screening table that identifies blood pressures needing further evaluation. 
 
 Use 24-hour ambulatory blood pressure monitoring to more exactly diagnose hypertension 
 
 Start blood pressure-lowering medications if lifestyle changes fail to reduce the blood pressure, or if the child has another condition like diabetes or kidney disease. 
 
 Use specific treatment patterns for special populations. 
 
 The report also notes that trained healthcare professionals in the office setting should diagnose hypertension if a child or adolescent has auscultatory-confirmed blood pressure readings ≥95th percentile on three different visits. 
 
 Additionally, adolescents with elevated blood pressure or hypertension should typically have their care transitioned to an appropriate adult care provider by age 22 years. This should include a transfer of information regarding hypertension etiology and past manifestations and complications of the patient's hypertension. 
 
 The authors noted that developing the new guidelines was the easy part. "Now we begin the harder work of implementing them to help children and adolescents," Kaelber said in a press release. 
 
 The authors concluded that they hope this report helps to provide direction for future research -- specifically regarding whether there is a specific blood pressure level in childhood that predicts adverse outcomes as in adults, as well as what the best diagnostic evaluation is to confidently exclude secondary causes of hypertension. 
 
 The authors reported no financial disclosures of interest. 
 
 Reviewed by F. Perry Wilson, MD, MSCE Assistant Professor, Section of Nephrology, Yale School of Medicine and Dorothy Caputo, MA, BSN, RN, Nurse Planner 
 
 1969-12-31T19:00:00-0500 

 New blood pressure tables and streamlined recommendations are among the changes in new pediatric hypertension guidelines that can help pediatricians identify and address this generally asymptomatic and often-unrecognized chronic disease. 
 
 The evidence-based clinical practice guideline (CPG) focuses on the diagnosis, evaluation and initial management of abnormal blood pressures in the ambulatory setting. Clinical Practice Guideline for Screening and Management of High Blood Pressure in Children and Adolescents, from the AAP CPG Subcommittee on Screening and Management of High Blood Pressure in Children, is available at http://pediatrics.aappublications.org/content/early/2017/08/21/peds.2017-1904 and is published in the September issue of Pediatrics. The guideline updates the 2004 The Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents from the National Heart, Lung, and Blood Institute (NHLBI). 
 
 Pediatric hypertension, occurring in 2%–5% of all pediatric patients, is one of the top five chronic diseases in children and adolescents. The diagnosis is missed in up to 75% of pediatric patients in primary care settings, and appropriate medication initiation occurs much less frequently than is indicated, according to current guidelines. 
 
 Beginning in 2014, the multidisciplinary subcommittee, which included a parent representative, reviewed approximately 15,000 articles published since the prior guideline was issued. 
 
 Highlights of the new pediatric hypertension guideline include: 
 
 development based on a strict evidence-based approach as recommended by the National Academy of Medicine and the NHLBI; 
 
 replacement of the term “prehypertension” with “elevated blood pressure”; 
 
 new normative blood pressure tables based on children with normal weight; 
 
 simplified screening table for identifying blood pressures needing further evaluation; 
 
 simplified blood pressure classification in adolescents 13 years of age and older that aligns with forthcoming American Heart Association/American College of Cardiology adult blood pressure guidelines; 
 
 a more limited recommendation to perform screening blood pressure measurement only at preventive care visits; 
 
 streamlined recommendations on initial evaluation and management of abnormal blood pressures; 
 
 expanded role for ambulatory blood pressure monitoring in both diagnosis and ongoing management of pediatric hypertension; 
 
 more limited recommendation on when to perform an echocardiogram in the evaluation of newly diagnosed hypertensive pediatric patients (generally only before medication initiation); 
 
 revised definition of left ventricular hypertrophy; 
 
 revised treatment goals based on published evidence; and 
 
 30 evidence-based key action statements and an additional 27 clinical recommendations based on expert opinion. 
 
 Dr. Flynn and Dr. Kaelber are among the co-authors of the clinical practice guideline and served as co-chairs of the subcommittee. 

 (CNN) More children and teens are likely to be categorized as having abnormal blood pressure during their annual wellness visits, based on new recommendations released Monday by the American Academy of Pediatrics. 
 
 High blood pressure is mostly a "silent" condition, with no visible symptoms. Yet it can have long-term health consequences, including cardiovascular disease. The new guidelines, aimed at prevention, were published Monday in the journal Pediatrics. They include new diagnosis tables based on normal-weight children. 
 
 The academy convened a 20-person committee to update the previous guidelines, issued in 2004 , and develop new evidence-based recommendations. As part of its work, the committee reviewed nearly 15,000 articles focused on diagnosis, evaluation and early management of abnormally high blood pressure in children and teens. 
 
 Obesity and family history 
 
 An estimated 3.5% of all children and teens in the United States have hypertension, according to the guidelines. 
 
 "The prevalence of 3.5% is based on fairly recent large-scale screening studies," said Dr. Joseph T. Flynn, lead author of the guidelines and a professor of pediatrics at University of Washington. In the past, the percentage of children diagnosed with high blood pressure was lower, he said: "based on previous studies, maybe 1% to 2%." 
 
 The cause of hypertension depends on the age group. 
 
 "In infants and very young children, we worry about an underlying cause like kidney disease," Flynn said. With older school-age children and teenagers, the cause is more likely to be primary hypertension, sometimes called essential hypertension, "where there's no specific problem," he said. "This is like adults." 
 
 "Obesity does contribute to higher blood pressure," he said. Yet the physiological mechanisms causing high blood pressure are very complicated, and not all kids who are overweight or obese are hypertensive, while some normal-weight kids may be. 
 
 "If, for example, a child is known to have kidney disease or heart disease, then they would be at higher risk for hypertension. Another group would be kids whose parents have hypertension," Flynn said. 
 
 The guidelines include updated blood pressure tables based on normal-weight children for more precise classifications of hypertension. As a result, more children will be categorized as needing treatment. 
 
 "Untreated, we believe that high blood pressure in a child will lead to high blood pressure when that child becomes an adult, so that would potentially lead to an increased risk of cardiovascular disease later in life," Flynn said, adding that untreated hypertension can also cause heart and kidney damage. 
 
 The new guidelines are aligned with those for adults according to Flynn. 
 
 "The blood pressure levels that are concerning in adults would also be concerning in an older teenager," meaning those age 13 and older. "It simplifies things for doctors," he said. 
 
 Takeaways for parents 
 
 The major thing parents need to know is that their children should have their blood pressure checked when they see a doctor, Flynn said. Also, know that hypertension can be managed with lifestyle change: for example, more exercise or changing the diet. Sometimes, though, the condition requires medication. 
 
 Another change in the new guidelines is an emphasis on confirmation of the diagnosis. 
 
 "Ambulatory blood pressure monitoring is a procedure in which the person wears a blood pressure cuff for 24 hours, and their blood pressure is measured periodically over 24 hours," Flynn said. "This is very important in children because there's a very high rate of what's called white coat hypertension, where blood pressure is high in the office (due to fear of doctors) but not at home." 
 
 The new recommendation is that ambulatory blood pressure should become standard practice in children after any abnormal in office reading, Flynn said. 
 
 Dr. Sophia Jan, director of general pediatrics at Cohen Children's Medical Center in New Hyde Park, New York, said the rationale behind the new guidelines makes sense. 
 
 With evidence that there may be consequences for kids whose high blood pressure is not treated at lower thresholds, it makes sense to treat them earlier than in the past, said Jan, who was not involved in the new recommendations. 
 
 What she would tell parents is that "we're not doing anything majorly different. We're still going to check your child's pressure when he or she comes for wellness child visits. That's what we've done always in the past." What's new is that "we may be quicker to recommend that you and your family help your child engage in lifestyle changes if your child's pressure is within a threshold that is lower than in the past. 
 
 "Everyone's loath to put kids on medicines if you don't have to, but we may need to get there a little bit faster than we have traditionally in the past," Jan said. 
 
 She said that she understood how difficult it is for families to be able to have full control over what their kids eat and how much physical activity they get. 
 
 "This is increasingly a public health problem," Jan said, since schools don't always have budgets that would allow for exercise programs and lots of veggies and fruits in school lunches. 
 
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 "As doctors, we recommend these lifestyle changes, yet in reality, it requires partnership with schools and public health agencies," she said. "We in the pediatric community did not necessarily appreciate to what degree kids were starting to exhibit what is traditionally thought of as an adult condition. Kids can show early signs of organ damage and increased risk for cardiovascular disease despite the fact that they're young."
– Parents bringing their kids to their well visits will likely review their height, weight, vaccinations, and now ... blood pressure. CNN reports on new guidelines issued by the American Academy of Pediatrics and printed in the September issue of the Pediatrics journal that include updated diagnosis tables based on kids within their normal weight range—and, based on these updates, it's likely that more kids and teens are going to be given a high blood pressure diagnosis. To revamp these hypertension guidelines, last updated in 2004, a 20-person committee looked at almost 15,000 articles revolving around abnormal blood pressure in kids and teens, which is caused by different reasons per age group (including underlying conditions like kidney disease in infants and little kids, and murkier causes for older kids and teens). But hypertension—which an AAP release notes occurs in 2% to 5% of all pediatric patients and falls within the top five chronic conditions for the under-18 set—is complex, with lead author Dr. Joseph Flynn noting to CNN that a variety of factors may be at work, including obesity and family history. No matter the cause, it's critical kids are checked, as scientists think untreated hypertension in kids may lead to an increased risk of cardiovascular disease later on. "If there is diagnosis of hypertension, there are many ways we can treat it … but because the symptoms are silent, the condition is often overlooked," study co-author David Kaelber tells MedPage Today. Parents should make sure blood pressure it routinely checked during doctor visits and managed through a healthy diet, regular exercise, and medication, if needed. (Bad for blood pressure: smog.)