High Blood Pressure in Children and Adolescents: Current Perspectives and Strategies to Improve Future Kidney and Cardiovascular Health

Abstract

Hypertension is one of the most common causes of preventable death worldwide. The prevalence of pediatric hypertension has increased significantly in recent decades. The cause of this is likely multifactorial, related to increasing childhood obesity, high dietary sodium intake, sedentary lifestyles, perinatal factors, familial aggregation, socioeconomic factors, and ethnic blood pressure (BP) differences. Pediatric hypertension represents a major public health threat. Uncontrolled pediatric hypertension is associated with subclinical cardiovascular disease and adult-onset hypertension. In children with chronic kidney disease (CKD), hypertension is also a strong risk factor for progression to kidney failure. Despite these risks, current rates of pediatric BP screening, hypertension detection, treatment, and control remain suboptimal. Contributing to these shortcomings are the challenges of accurately measuring pediatric BP, limited access to validated pediatric equipment and hypertension specialists, complex interpretation of pediatric BP measurements, problematic normative BP data, and conflicting society guidelines for pediatric hypertension. To date, limited pediatric hypertension research has been conducted to help address these challenges. However, there are several promising signs in the field of pediatric hypertension. There is greater attention being drawn on the cardiovascular risks of pediatric hypertension, more emphasis on the need for childhood BP screening and management, new public health initiatives being implemented, and increasing research interest and funding. This article summarizes what is currently known about pediatric hypertension, the existing knowledge-practice gaps, and ongoing research aimed at improving future kidney and cardiovascular health.

Keywords: blood pressure; cardiovascular health; children; hypertension; kidney disease; pediatric.

Figure 1

Barriers and knowledge-practice gaps leading to suboptimal pediatric hypertension care. Estimates are provided for the proportion of children in each of the referenced studies that fit the stated description. These are included to provide approximations of the proportion of children who receive suboptimal care at each stage, including population BP screening, follow-up of elevated BP readings, diagnosis of hypertension, management of hypertension, and adequate BP control. Details of the specific populations included and study methods can be found in the references provided. Aside from the studies of hypertension control in children with CKD, all of the other referenced studies were conducted in the United States (and 1 Canadian study²¹). There may be significant global practice variation in pediatric hypertension care. Without data from other countries, it is not possible to extrapolate beyond the North American context. We used existing guidelines at the time of study publication to define what proportion of children received “suboptimal care.” These guidelines were the NHLBI fourth report (from 2004 to 2017), the AAP 2017 guidelines (from 2017 to present), and the KDIGO guidelines (for children with CKD).^,, ABPM, ambulatory BP monitoring; AAP, American Academy of Pediatrics; BP, blood pressure; CKD, chronic kidney disease; KDIGO, Kidney Disease Improving Global Outcomes; NHLBI, National Heart Lung and Blood Institute.

Figure 2

Strategies to improve global pediatric hypertension care. ACEi, angiotensin-converting enzyme inhibitor; ARB, angiotensin receptor blocker; CCB, calcium channel blocker.