Why is high blood pressure underdiagnosed in children?
A new study has found that about one in 30 children between 3 and 18-years-old have significantly high blood pressure or hypertension for their age.
An American childhood health crisis is developing because of the massive weight gain of the current generation of children compared to past generations. In adults, excess weight leads to vast increases in Type 2 diabetes and hypertension among many other diseases. Now our increasingly overweight children are developing the same obesity related diseases seen in adults, but 20 to 40 years earlier.
It didn't surprise me a study in Pediatrics published online this week found that about one in 30 children between 3 and 18-years-old have significantly high blood pressure (or hypertension) for their age. The article also shows that primary care clinicians do not make the diagnosis very often and almost never treat it. If 3.3 percent of all children in the U.S. have untreated high blood pressure, that is over 2 million children and adolescents who are injuring their kidneys, hearts, and blood vessels while increasing their future chance of heart disease and stroke.
Over a dozen years ago an expert panel report suggested many changes in childhood hypertensive care was published, but only one important change in clinical care occurred from it. Primary care pediatric clinicians started routinely taking blood pressures during all well visits age 3 and over and at many sick visits. So while in 2004 less than half of children had good blood pressure documentation in their charts, now 97 percent have this data. The availability of these blood pressure readings and the onset of electronic health records (EHR) allowed this new report to look at over 400,000 medical charts and see what was happening with the blood pressure data.
It showed that when a child has three elevated BPs at three different visits less than 25 percent were designated as hypertensive in their problem list. Of those listed as hypertensive, only one in 20 was treated. Why do pediatric offices gather this data and not do anything about it? It's complicated.
1. To know if a child's blood pressure is abnormal one must look at complex charts (or have the computer do it) for age, size, and gender. If a short 8-year-old boy has a BP of 118/76 that is off the charts high while it would be normal for an adult. So what is an elevated BP is sometimes not obvious at first glance.
2. The BP has to be elevated at three different visits or one could confuse anxiety with hypertension. Most practitioners do not routinely check the vital signs over that much time and most EHRs are not set up to notify the practitioner that there is a problem.
3. Even if the high blood pressure is noticed, the vast majority of general pediatricians do not feel comfortable in doing more than trying to get child to do life style changes in an attempt to lose weight. Many primary care doctors want the prescribing of long-term anti-hypertension medicines in children done by a heart or kidney pediatric specialist, but these experts are not available in many locales and there are far too few of them to take care of the estimated two million hypertensive children and adolescents.
So what can we pediatric practitioners do? We can reprogram our computers to alert us when there are multiple high BP values in a child's chart and maybe the future interaction of EHRs at different sites can learn to work together on this problem. Primary care practitioners can reach a consensus on the best initial pathway of treating high blood pressure in children and adolescents so that they feel comfortable using medication when life-style changes fail to curb the elevated pressures. This is a treatable problem, but we have to learn how to treat it best.
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