ONGOING COLUMNS: Hot Topics in Pediatric Nursing
Most pediatric providers do not think of hypertension as a common diagnosis in children and adolescents. However as reported by the American Academy of Pediatrics (AAP, 2017), prevalence of hypertension has increased significantly since 1988, with most cases going undiagnosed or treated. It is estimated that 3.5% of children and adolescents have hypertension (AAP). In August 2017, AAP published a 74-page report on guidelines for hypertension screening and management (Flynn et al., 2017). This report updates guidelines previously published in 2004 by the National Heart, Lung, and Blood Institute. The authors reviewed almost 15,000 published research studies between January 2004 and July 2016 and references 574 of these studies (Flynn et al.).
There are significant changes in the 2004 guidelines in the areas of: 1) replacement of the term prehypertension with elevated blood pressure (BP); 2) inclusion of a comprehensive BP table based on normal weights, gender, and age; 3) a simplified screening table that identifies BP needing further evaluation; 4) revised recommendations for initial evaluation and management; and 5) expanded recommendations for primary care BP monitoring (Flynn et al., 2017). This comprehensive set of guidelines provides a detailed review of: epidemiology and clinical significance, definition of hypertension; BP measurement techniques; primary and secondary predictors of hypertension in children; key points on diagnostic evaluation; treatment recommendation including pharmacologic and nonpharmacologic modalities including lifestyle changes; prevention; and overall roles of providers.
There are many key messages in this guideline for pediatric nurses. First and foremost, it is critical to understand that prevalence of hypertension has dramatically increased in recent decades and high BP during childhood is directly related to hypertension in adult years. This in turn leads to an increased risk for heart disease and stroke. These new guidelines encourage pediatric providers to measure and record BP at every well-child visit for children 3 years or older, whether or not the child appears to have any risk factors such as family history, obesity, or comorbidities. The report goes further to suggest parents ask for BP monitoring if not routinely done. Although a diagnosis of elevated BP is made after three consecutive high readings, the extensive tables in the guideline provide an easy interpretation and opportunity for anticipatory or preventative guidance. A recommendation is made to consider using a 24-hour ambulatory BP monitor with every child with an elevated BP so to avoid the “white coat phenomenon.” Best BP measurement practices are detailed and include: 1) having the child sit in a quiet room for 3 to 5 minutes prior to measurement with back supported and legs uncrossed; 2) use of a correct age and size appropriate BP cuff; and 3) guidelines for auscultatory BP measurement as well as measurement in the legs (Flynn et al., 2017). Prevention and treatment measures address pharmacologic as well as nonpharmacologic approaches that include lifestyle changes to diet and physical activity. In a recent interview, Sophia Jan, director of pediatrics at Cohen Children's Medical Center in Hyde Park, New York stated, as providers, “we recommend these lifestyle changes, yet in reality, it requires partnership with schools and public health agencies. We in the pediatric community did not necessarily appreciate to what degree kids were starting to exhibit what traditionally is 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 are young” (Scutti, 2017).
Pediatric nurses have a key role in prevention and management of this life threatening diagnosis in young children and teens. Review the AAP (2017) guidelines and make sure they are being incorporated into your clinical practice.
Flynn J. T., Kaelber D. C., Baker-Smith C. M., Blowey D., Carroll A. E., Daniels S. R., ..., Urbina E. M.for the Subcommittee on screening and management of high blood pressure in children. (2017). Clinical practice guideline for screening and management of high blood pressure in children and adolescents. Pediatrics
, 140(3), e20171904. doi:10.1542/peds.2017-1904