Wednesday, August 22, 2007

Study: Hypertension under-diagnosed in kids

Study: Hypertension under-diagnosed in kids
By Deborah L. Shelton
Copyright © 2007, Chicago Tribune
3:59 PM CDT, August 21, 2007


Pediatric records suggest doctors fail to diagnose high blood pressure in most children and teenagers who have it, an oversight that could have devastating health consequences once they become adults, researchers reported today.

The study, published in this week's Journal of the American Medical Association, found that among children whose blood pressure readings indicated hypertension, only 26 percent had the diagnosis documented in their electronic medical records.

If the findings are extrapolated nationwide, as many as 1.5 million children and teens could have undiagnosed high blood pressure, said Dr. David C. Kaelber, a pediatrician at Boston Children's Hospital and a study co-author. That compares with about 500,000 children who have been correctly diagnosed.

"I expected to find some under-diagnosis, but it was the magnitude of the under-diagnosis that was most striking," Kaelber said. He said the study was "a wake-up call for providers as well as parents that we need to become much more educated and careful about looking at blood pressure in children."

The new study adds to recent research suggesting that high blood pressure is becoming more common in children and adolescents in the U.S., paralleling the nation's obesity epidemic.

The latest findings were sobering but not surprising, said Dr. Stephen Daniels, chairman of pediatrics at University of Colorado School of Medicine and pediatrician-in-chief at The Children's Hospital at Denver. "Even in adults, it's clear that hypertension isn't recognized as often as it should be," he said.

Blood pressure refers to the force exerted on artery walls as blood flows through the body. Untreated hypertension usually does not cause life-threatening problems in children because the damaging effects occur over time, but it has been linked to heart attacks, strokes and kidney failure in adults.

Normal blood pressure for adults is a systolic pressure below 120 and a diastolic pressure of 80 as measured in millimeters of mercury. Systolic pressure between 120 and 139 or a diastolic pressure between 80 and 89 means prehypertension, or slightly elevated blood pressure that often leads to full-blown hypertension.

Identifying the condition in children, however, is far more complicated. Guidelines developed by medical experts define hypertension as blood pressure at or higher than the 95th percentile for age, sex and height during three office visits. Prehypertension is defined as average blood pressure at or higher than the 90th percentile for age, sex and height, or a reading of more than 120 over 80.

That's where it gets sticky. For example, the 95th blood pressure percentile for a 15-year-old girl in the 75th percentile of height is 129 over 84, but the 95th percentile for an 8-year-old boy in the 10th percentile of height is 112 over 76. Although tables are available to help clinicians determine whether blood pressure is abnormal, they don't always use them.

The JAMA study examined the records of more than 14,000 pediatric patients, ages 3 to 18, who were seen at least three times during routine checkups between June 1991 and September 2006 in outpatient clinics at a large medical center in the Cleveland area.

Medical records indicated that 507 of the children had hypertension, 3.6 percent of the total. But only 26 percent of them had a documented diagnosis. Of the 485 children with prehypertension, only 11 percent of the cases were documented.

Older and taller children with hypertension were more likely to be identified, the authors said, because they are more likely to have readings above 120 over 80, the normal blood pressure for adults.

Hypertension in children has been correlated with low birth-weight, excess weight and a family history of high blood pressure. If not identified and addressed early, either with lifestyle changes or medication, the chance of preventable organ failure in adulthood is greatly increased, the authors said.

"We are seeing more and more kids who are going to be diagnosed with hypertension, just as we are seeing more and more kids diagnosed with diabetes. This is a serious public health issue," said Evanston pediatrician Dr. Irwin Benuck, who also practices at Children's Memorial Hospital in Chicago. "We need to teach our kids to eat healthy and exercise and not be couch potatoes like so many are."

The solution likely will be multifaceted, experts said. Parents should ask about their children's blood pressure and learn what the readings mean. Greater education of pediatricians and other clinicians about high blood pressure in children also would help, as would wider use of electronic medical records and computerized information systems, they said.

dshelton@tribune.com

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