European Primary Care Cardiovascular Society

New American guidelines result in more children with hypertension

Prevalence and Severity of High Blood Pressure Among Children Based on the 2017 American Academy of Pediatrics Guidelines

Sharma AK, Metzger DL, Rodd CJ. - JAMA Pediatr 2018; published online ahead of print

Introduction and methods

When blood pressure (BP) was redefined for adults, the proportion of US adults with elevated BP was increased from 32% to 46% [1,2]. New guidelines for the diagnosis and management of elevated BP in children were also published recently, in which the percentile values were recalculated after excluding individuals who are overweight or obese. As a result, the percentile values were lowered by about 2 or 3 mm Hg across the range of percentiles. For adolescents aged 13 years or older, what was previously called pre-hypertension is now called elevated BP, since the adult cut-points apply now for adolescents as well [3,4]. The net effect of changes in population percentiles and diagnostic cut-offs is not known.

In this analysis, the consequences of the new guidelines on the prevalence and severity of elevated BP was assessed in an unselected and generally healthy sample of 15,647 children aged 5-18 years from the 1999-2014 National Health and Nutrition Examination Surveys (NHANES) [5]. Moreover, clinical and laboratory risk factors were evaluated for children whose BP level was reclassified upward. Auscultatory BP was measured in a single ambulatory sitting.

Main results


Based on the new BP definitions for children, the estimated population prevalence increased from 11.8% to 14.2%. Children whose BP was reclassified upward were more likely to be male, taller, younger, overweight or obese, and have higher cholesterol and hemoglobin A1c levels. The authors conclude that the new guidelines allow for early CV prevention in more children at higher risk.

Editorial comment

In his editorial article, Daniels [6] criticizes the use of the NHANES database for this study, because the diagnosis of hypertension in children requires a persistent elevation of BP, but multiple BP measurements are not available in NHANES. Therefore, he notes that the prevalence of hypertension in children will be lower than that calculated by Sharma et al. The author also notes that ‘These “new” cases of elevated blood pressure were more likely to be found among children who were overweight or obese and those with abnormal lipid profiles and increased hemoglobin A1c levels (prediabetes). So, how should we evaluate whether the new clinical practice guidelines provide the best estimate of the prevalence of elevated blood pressure or not?’, and he concludes: ‘However, to know how much lower this prevalence will be will require future studies with longitudinal measurements. While we wait for additional studies, clinicians should use the new American Academy of Pediatrics Clinical Practice Guidelines in their practice. There are many elements that make the new guidelines easier to use than the old ones. In addition, use in practice will provide important clinical data that can ultimately contribute to improvements in our clinical approach to pediatric hypertension.’


Show references

Find this article online at JAMA Pediatr