The goal of this systematic review and meta-analysis was to assess the prevalence of hypertension in the general pediatric population.
Question Addressed:
- What is the prevalence of hypertension in the general pediatric population?
How common is high blood pressure (BP) among children and adolescents ages 19 and younger? In a systematic review and meta-analysis of 47 articles (1994-2018), researchers reported that hypertension affected 4% of children worldwide.
Compared with the 1.9% prevalence seen in children and adolescents with normal weight, Yajie Zhu, PhD, of the George Institute for Global Health at the University of Oxford in England, and colleagues found a higher prevalence of hypertension in overweight (4.99%) and obese (15.27%) children.
Action Points
- In a systematic review and meta-analysis of 47 articles, researchers reported that hypertension affected 4% of children ages 19 and younger worldwide.
- Note that the findings suggest that childhood hypertension is becoming more common in the general pediatric population, representing a considerable public health challenge.
Hypertension in adults, which can take years to develop, is known to be a major risk factor for more than heart disease. Left uncontrolled, the condition can damage the arteries, brain, kidneys, and eyes, among many other effects on the body. About half of people with untreated hypertension die of heart disease. Different lines of evidence have emerged that show that hypertension has immediate adverse effects on the heart and brain and, if present during childhood and adolescence, is linked to markers of subclinical atherosclerosis in adulthood.
From a public health perspective, reliable estimates of the prevalence of childhood hypertension could inform management of the condition and the prevention of its consequences, as well as aid in evidence-based health resource allocation and policy making, according to the group.
Because BP is so variable, hypertension definitions require systolic BP (SBP) or diastolic BP (DBP) to be persistently in the ≥95th percentile on three separate occasions, an approach recommended for children up to age 13 in the most recent American Academy of Pediatrics clinical practice guidelines. Adult guidelines for elevated BP (120-129/<80 mm Hg) and hypertension (BP >130/80 mm Hg) are used for children ≥13 years, but these measurements also need to be elevated persistently on three separate occasions.
“In children, the measurement of blood pressure is relatively complicated and unstable, so it needs to be repeated across at least three different visits to avoid false positive cases,” Zhu told MedPage Today. “Until recently, reliable estimates of childhood hypertension prevalence were lacking.” A previous meta-analysis reported the pooled prevalence of childhood hypertension at 11.2%, for example, but that analysis included studies with only one BP measurement.
Because studies included in the current review and meta-analysis were performed before new guidelines became available, the researchers used standardized definitions of hypertension based on the fourth report from the National High Blood Pressure Education Program (NHBPEP) working group for children and adolescents. Standardized definitions for some of the key BP metrics in this review were:
- Prehypertension: an SBP and/or DBP ≥90th percentile but <95th percentile (for age, sex, and height) or ≥120/80 mm Hg
- Hypertension: an SBP and/or DBP ≥95th percentile (for age, sex, and height) on ≥3 separate occasions
- Stage 1 hypertension: an SBP and/or DBP ≥95th percentile (for age, sex, and height) but ≤99th percentile plus 5 mm Hg (for age, sex, and height) on ≥3 separate occasions
- Stage 2 hypertension: an SBP and/or DBP >99th percentile plus 5 mm Hg (for age, sex, and height) on ≥3 separate occasions
More than two-thirds of the articles (68%) were published from 2010 onwards and the most commonly used device for BP measurement was a mercury sphygmomanometer (40.4%), followed by an oscillometric sphygmomanometer (34%). More than half the studies were conducted in low- and middle-income countries and no single study had an excessive influence on the pooled prevalence.
Pooled prevalence estimates for prehypertension and stage 2 hypertension in children ages 19 and younger were 9.67% and 0.95%, respectively. During a 15-year period (2000-2015), the prevalence of childhood hypertension across a specified age range (6 to 19 years) rose at a relative rate of 75% to 79%. A trend of hypertension with respect to age was also observed. In 2015, the prevalence of hypertension ranged from 4.32% among children age 6 years to 3.28% among those age 19, and peaked at 7.89% among children age 14.
While Zhu’s group unified the definitions of childhood hypertension and its subtypes before pooling the prevalence estimates, they acknowledged the presence of substantial heterogeneity. Uncertainties for pooled prevalence estimates were increased because of the small number of included studies for prehypertension, stage 1 hypertension, and stage 2 hypertension in children. Researchers also noted that the prevalence at the regional level was not optimal for the six World Health Organization regions covered.
Source References: JAMA Pediatrics 2019; DOI: 10.1001/jamapediatrics.2019.3310
Editorial: JAMA Pediatrics 2019; DOI: 10.1001/jamapediatrics.2019.3333
Study Highlights and Explanation of Findings:
Using 47 studies that covered urban, rural, and mixed childhood populations in many different countries, combined with a strict definition of hypertension, researchers were able to quantitate its overall prevalence as 4% in children 19 years or younger. Overweight and obese children were more likely to have hypertension than their normal-weight counterparts. Among children ages 6 to 19, the prevalence of hypertension increased from 75% to 79% from 2000 through 2015.
Researchers noted that, to the best of their knowledge, this was the first systematic review and meta-analysis to explore the global prevalence of childhood hypertension based on BP measurements on at least three separate occasions. Study strengths included comprehensive search strategies, a double review process, and stringent selection criteria, increasing the chances of generalizability by selecting studies that were conducted in the general pediatric population.
Hypertension continued to increase before the onset of puberty and during puberty, but this may not be sustained after puberty. “This finding is consistent with the clinical observation of adolescents with persistently high blood pressure, especially during periods of rapid growth in height, who can then have normal blood pressure later in adolescence and young adulthood,” wrote Stephen Daniels, MD, PhD, of the University of Colorado in Aurora, in an accompanying editorial. “It is important for adolescents with hypertension to be followed up over time to determine which adolescents will become healthier and which will develop persistent hypertension.”
Although the authors were not able to use the most recent definition of hypertension, Atul Sharma, MD, and colleagues pointed out that the use of the new clinical practice guidelines would result in elevated BP using National Health and Nutrition Examination Survey data in a separate JAMA Pediatrics study. By extension, Daniels reasoned that the prevalence of hypertension might have been increased in the current analysis.
Consistent with a prior study, the group found systolic hypertension to be common in children and adolescents. Daniels noted that elevated SBP is more closely associated with left ventricular hypertrophy than DBP. Therefore, increases in SBP might not be linked to stress and anxiety “and should be considered to be important for further workup and potential treatment.”
BP measurements should be measured at routine health maintenance visits, and when elevated BP is found, it is important for additional measurements to be made to determine whether hypertension is present, Daniels concluded.
Reviewed by Robert Jasmer, MD Associate Clinical Professor of Medicine, University of California, San Francisco
Primary Source
JAMA Pediatrics
Secondary Source
JAMA Pediatrics
Additional Source
MedPage Today
Source Reference: George J “More Children Have High Blood Pressure” 2019.
https://www.medpagetoday.org/neurology/generalneurology/82694?_ga=2.88878491.1081251847.1570409347-265074527.1569866268
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