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A study of more than 14,000 Ohio children has found, alarmingly, that nearly three-quarters of those with three or more elevated blood-pressure readings had never been diagnosed with hypertension. Nationwide, that amounts to more than a million children whose increased risk for heart disease, stroke and kidney disease is going unrecognized, researchers report in the August 22/29 issue of JAMA.
Hypertension, with an estimated prevalence of between 2 percent and 5 percent, is a common chronic disease in children and is increasing in prevalence with the pediatric obesity epidemic. Diagnosis of hypertension in children is complicated because normal and abnormal blood pressure values vary with age, sex, and height, according to background information in the article.
David Kaelber, MD, of the Children's Hospital Boston Primary Care Center, with colleagues at Case Western Reserve University, Cleveland, Ohio, studied 14,187 children aged 3 to 18 who were observed at least three times for well-child care between June 1999 and September 2006 in outpatient clinics.
Overall, 507 children (3.6 percent) met criteria for hypertension, but of these, only 131 (26 percent) had a diagnosis of hypertension or elevated blood pressure documented in the electronic medical record; i.e., 376 of 507 participants (74 percent) had undiagnosed hypertension. Another 485 children (3.4 percent) met criteria for prehypertension; of these children, 55 (11 percent) had a diagnosis of hypertension or elevated blood pressure documented in the electronic medical record.
Younger kids of normal weight and height were most likely to be missed. Kaelber hopes the findings will be a wake-up call for clinicians.
"Identification of elevated blood pressure in children meeting pre-hypertension or hypertension criteria is important because of the increasing prevalence of pediatric weight problems and because secondary hypertension is more common in children than adults, requiring identification and appropriate work-up. If abnormal blood pressure is not identified by a patient's pediatric clinician, it may be years before the abnormal blood pressure is detected, leading to end-organ damage. Because effective treatments for abnormal blood pressure exist, these long-term sequelae can be avoided with early diagnosis," the authors write.
"Although this study identifies the problem of undiagnosed hypertension in children, it also points to the potential of electronic medical records to help address this issue. The relatively poor identification of abnormal blood pressure could be remedied by a clinical decision support algorithm built into an electronic medical record that would automatically review current and prior blood pressures, ages, heights, and sex to determine if abnormal blood pressure criteria had been met. The algorithm could indicate if any abnormal blood pressure already existed and prompt the pediatric clinician that the child appears to have undiagnosed abnormal blood pressure. In addition, the clinical decision support algorithm could provide guideline-based evaluation, treatment and parent/patient education materials to the clinician."
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