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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 , 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 麻豆传媒.

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.

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