University Of Maryland Medicine’s Dr. Carissa Baker-Smith a Lead Author on AAP’s Newly Issued Guideline for Screening and Management of High Blood Pressure in Children and Adolescents

First Update to Guideline in 13 Years Uses Evidence-Based Approach to Help Clinicians and Parents Recognize and Treat Hypertension in Children

Baltimore, Md., August 21, 2017 – The diagnosis, management and treatment of hypertension in children – a leading cause of chronic disease and disability for millions of Americans – is the subject of a new clinical practice guideline released today by the American Academy of Pediatrics. Carissa Baker-Smith, MD, MS, MPH, FAAP, FAHA, assistant professor of pediatrics at the University of Maryland School of Medicine (UM SOM) and a pediatric cardiologist at the University of Maryland Children’s Hospital (UMCH), is a lead author of "Clinical Practice Guideline for Screening and Management of High Blood Pressure in Children and Adolescents," the first update in 13 years on this topic. The guideline provides evidence-based recommendations that address how we define, diagnose and treat high blood pressure in children.

The guideline has been formally endorsed by the American Heart Association and by the American College of Cardiology. Some key points in the guideline include:

• It is estimated that about 2 million children in the U.S. have high blood pressure, and many don't know they have it.¹
• A major risk factor for hypertension in youth is obesity. In the past 30 years, childhood obesity has more than doubled in children and quadrupled among adolescents.^{1, 2}
• Hypertension is prevalent in 3.8 percent to 24.8 percent of youth with unhealthy weight and obesity.

"If we hope to have healthy adults, we have to start with healthy kids," said Dr. Baker-Smith. "In general, about 3 percent of children have high blood pressure, but a quarter or more of children who are of an unhealthy weight have high blood pressure. For a child who is of an unhealthy weight and who has obesity, the higher their body mass index³ (BMI), the more likely they are to have high blood pressure. And the unhealthier the weight, the higher the blood pressure is likely to be."

In many cases, hypertension is silent and may not have any symptoms associated with it, according to Dr. Baker-Smith. If unrecognized and unmanaged, high blood pressure in children puts stress on the heart over time, causing the heart muscle to thicken abnormally. High blood pressure is also a major contributor to heart failure, stroke and other complications later in life.

Dr. Baker-Smith advises parents: "Pay attention when the pediatrician says that your child's weight-for-height is increasing in an unhealthy way. Heed to the recommendation for your child to cut back on extra calories and exercise more, because unhealthy weight is a major risk factor for high blood pressure. Our eye's ability to assess whether or not a child is of an unhealthy weight is not very good. Healthy lifestyle and a healthy weight may be all that is required to control a child's blood pressure."

According to this new guideline, as long as a child's blood pressure is not too high, lifestyle interventions should be trialed first in order to control the blood pressure. But when lifestyle intervention is ineffective or families are less compliant with the recommendation, then sometimes medications are required.

Methodology

The guideline writing committee reviewed almost 15,000 references to finally create 30 "key action statements" designed to provide pediatricians and sub-specialists with a framework by which they can practice and care for children with suspected hypertension. The guideline's key action statements start from when a child should be screened for hypertension beginning at 3 years old all the way through to the transition of care from a pediatric provider to an adult provider for high blood pressure.

Dr. Baker-Smith served as epidemiologist and methodologist for the creation of the guideline, so was tasked with determining the guideline’s breadth and depth, organizing the literature search and literature archival process, and facilitated all technical aspects of creating this report. She was also a lead author of the guideline and is the first author of the technical report that follows the clinical practice guideline. The writing committee was comprised of 17 representatives from various pediatric groups, including a quality expert, pediatricians, nephrologists, and pediatric cardiologists. Notably, there was also a parent member who provided a family's perspective.

The updated recommendations for the diagnosis and management of high blood pressure in children incorporate new evidence and data that has been developed and published since the 2004 report.

In the 2004 report, there were tables that pediatric providers used to define high blood pressure in children. With the 2017 guideline, those tables have been revised to take out a subset of children who are of an unhealthy weight because the prevalence of hypertension in these children is higher than in normal-weight children, so those children were excluded in order to determine appropriate blood pressure cut-offs. Providers will notice that the cut-offs for normal blood pressure are lower than previously determined, and so there may be many more children who are found to have elevated blood pressure or true hypertension as a result of the revised guideline.

"Through a systematic analysis of the best-available information, Dr. Baker-Smith and her colleagues have produced an excellent, evidence-based guideline that will serve pediatricians well," says UM SOM Dean E. Albert Reece, MD, PhD, MBA, who is also the vice president for medical affairs at the University of Maryland and the John Z. and Akiko K. Bowers Distinguished Professor.

Steven J. Czinn, MD, the Drs. Rouben and Violet Jiji Endowed Professor of Pediatrics, UM SOM Chair of the Department of Pediatrics and Director of UMCH, says, "The updated guideline covers the span of what those of us who care for children and adolescents see every day. It provides a compass that we can use to guide our practice in order to better screen and treat hypertension in children."

While the guideline was written primarily for clinicians, parents and others who care for children can also learn from it. During a child's routine visit with the pediatrician, parents should expect the child to have a full vitals assessment including blood pressure screening starting at age 3 years (and younger for certain children who are at a higher risk for developing hypertension). They should also expect the provider to obtain the child's birth history given that aspects such as premature birth is a risk factor for hypertension. Parents should also expect the provider to inquire about family history, since high blood pressure can be hereditary.

1. Source: Journal of the American Medical Association (JAMA)
2. Source: National Center for Health Statistics
3. Definition of body mass index (BMI) from the Centers for Disease Control and Prevention: a widely used screening tool for measuring both overweight and obesity. BMI percentile is preferred for measuring children and young adults (ages 2–20) because it takes into account that they are still growing, and growing at different rates depending on their age and sex. Health professionals use growth charts to see whether a child's weight falls into a healthy range for the child's height, age, and sex. Children with a BMI at or above the 85th percentile and less than the 95th percentile are considered overweight. Children at or above the 95th percentile have obesity.

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Flynn JT, Kaelber DC, Baker-Smith CM, et al. Clinical Practice Guideline for Screening and Management of High Blood Pressure in Children and Adolescents. Pediatrics. 2017;140(3):e20171904

About the University of Maryland School of Medicine

Commemorating its 210th Anniversary, the University of Maryland School of Medicine was chartered in 1807 as the first public medical school in the United States. It continues today as one of the fastest growing, upper-tier biomedical research enterprises in the world – with 43 academic departments, centers, institutes, and programs; and a faculty of more than 3,000 physicians, scientists, and allied health professionals, including members of the National Academy of Medicine, and distinguished recipient of the Albert E. Lasker Award in Medical Research. With an operating budget of more than $1 billion, the School of Medicine works closely in partnership with the University of Maryland Medical Center and Medical System to provide research-intensive, academic and clinically based care for more than 1.2 million patients each year.

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About the University of Maryland Children's Hospital

The University of Maryland Children's Hospital is recognized throughout Maryland and the mid-Atlantic region as a resource for critically and chronically ill children. UMCH physicians and staff excel in combining state-of-the-art medicine with family-centered care. More than 100 physicians specialize in understanding how to treat conditions and diseases in children, including congenital heart conditions, asthma, epilepsy and gastrointestinal disorders. The Drs. Rouben and Violet Jiji Neonatal Intensive Care Unit (NICU) provides the highest level of care to the tiniest newborns.