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Is identifying elevated blood pressure (BP) in a child or adolescent predictive of adult cardiovascular disease? We agree with Dr Thompson that a definitive answer is not yet known based on currently available data, although most pediatric hypertension experts would consider this a question already adequately addressed from analyses of BP-tracking studies.[1] Additional data from long-term follow-up of established cohorts such as the Fels Longitudinal Study[2] add further weight to this impression. A more important question might be “Is there value in identifying hypertension as early in the disease process as possible?” While it is true that not all children with high BP are destined to have hypertension as adults, these children are likely the ones most at risk for BP problems early in adulthood. Data suggest that vascular damage begins early in the disease process. Thus, measurement of BP in childhood may indeed have important future ramifications.

All BP devices are subject to inaccuracies, regardless of the age of the person whose BP is being measured. We have reported that children with even a single occurrence of high BP are at increased risk for developing sustained hypertension.[3] However, the recommendations for obtaining repeat BP measurements in children are mostly based on the lability of BP in childhood, a point recently highlighted in a school screening study conducted in Iceland.[4] Given this, it is appropriate to obtain repeat BP measurements in children in order to avoid overdiagnosis.

We acknowledge and even share Dr Thompson's concerns regarding the unknown long-term effects of antihypertensive medications in children and adolescents. Indeed, one of us (JF) was a member of the National High Blood Pressure Education Program Working Group that recommended limiting use of antihypertensive medications in the young to a limited set of circumstances precisely for this reason (Fourth Report).[5] However, we would also point out that as of this date, all classes of antihypertensive medications have been studied in pediatric clinical trials, and thousands of children have been exposed to antihypertensive medications in the clinical trial setting. Follow-up of children enrolled in these trials has generally been of similar duration as efficacy studies conducted in adults, and has not revealed adverse effects significantly different from those seen in adults. Decades-long studies of children treated with antihypertensive medications are not feasible; therefore, we are comfortable with the current guidelines for their selective use as outlined in the Fourth Report.

Finally, we must return to our major concern with the US Preventive Services Task Force (USPSTF) analysis, a point not directly addressed by Dr Thompson: That it may lead to widespread abandonment of BP measurement in children by primary care providers. Previous USPSTF reports such as their 2012 statement regarding screening for prostate cancer have received inordinate attention in the lay media, and the potential for misinterpretation and misapplication have been raised by others.[6] We are not alone in our concern that the report may have unintended consequences in the primary care setting.[7] Even if one concedes that the current evidence is insufficient to recommend screening for primary hypertension “to prevent subsequent cardiovascular disease in childhood or adulthood” we would argue that there are other valid reasons to evaluate BP children. We urge the USPSTF to make it clear in their final report that there are indeed merits to measuring BP in the young, and that providers should continue current practice pending the additional long-term data on pediatric hypertension that we agree are sorely needed.

References

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  • 1
    Chen X, Wang Y. Tracking of blood pressure from childhood to adulthood: a systematic review and meta-regression analysis. Circulation. 2008;117:317180.
  • 2
    Carrico RJ, Sun SS, Sima AP, Rosner B. The predictive value of childhood blood pressure values for adult elevated blood pressure. Open J Pediatr. 2013;3:116126.
  • 3
    Redwine KM, Acosta AA, Poffenbarger T, et al. Development of hypertension in adolescents with pre-hypertension. J Pediatr. 2012;160:98103.
  • 4
    Eliasdottir SB, Steinthorsdottir SD, Indridason OS, et al. Comparison of aneroid and oscillometric blood pressure measurements in children. J Clin Hypertens (Greenwich). 2013;Sep 20. [Epub ahead of print]
  • 5
    National High Blood Pressure Education Program Working Group on High Blood Pressure in Children and Adolescents. The fourth report on the diagnosis, evaluation, and treatment of high blood pressure in children and adolescents. Pediatrics. 2004;114:555576.
  • 6
    Catalona WJ, D'Amico AV, Fitzgibbons WF, et al. What the U.S. Preventive Services Task Force missed in its prostate cancer screening recommendation. Ann Intern Med. 2012;157:1378.
  • 7
    Falkner B. Screening for hypertension in children and adolescents. http://pediatrics.aappublications.org/content/131/3/490.long/reply#pediatrics_el_55463. Accessed November 1, 2013.