Clinical Practice Guideline for Screening and Management ...

1 Guidance for the Clinician in Rendering Pediatric Care Clinical Practice Guideline . Clinical Practice Guideline for Screening and Management of High blood pressure in Children and Adolescents Joseph T. Flynn, MD, MS, FAAP, a David C. Kaelber, MD, PhD, MPH, FAAP, FACP, FACMI, b Carissa M. Baker-Smith, MD, MS, MPH, FAAP, FAHA, c Douglas Blowey, MD, d Aaron E. Carroll, MD, MS, FAAP, e Stephen R. Daniels, MD, PhD, FAAP, f Sarah D. de Ferranti, MD, MPH, FAAP, g Janis M. Dionne, MD, FRCPC, h Bonita Falkner, MD, i Susan K. Flinn, MA, j Samuel S. Gidding, MD, k Celeste Goodwin, l Michael G. Leu, MD, MS, MHS, FAAP, m Makia E. Powers, MD, MPH, FAAP, n Corinna Rea, MD, MPH, FAAP, o Joshua Samuels, MD, MPH, FAAP, p Madeline Simasek, MD, MSCP, FAAP, q Vidhu V.

2 Thaker, MD, FAAP, r Elaine M. Urbina, MD, MS, FAAP, s SUBCOMMITTEE ON Screening AND Management OF HIGH blood pressure IN CHILDREN. These pediatric hypertension guidelines are an update to the 2004 Fourth abstract Report on the Diagnosis, Evaluation, and Treatment of High blood pressure in Children and Adolescents. Significant changes in these guidelines include (1) the replacement of the term prehypertension with the term elevated blood pressure , (2) new normative pediatric blood pressure (BP) aDr. Robert O. Hickman Endowed Chair in Pediatric Nephrology, Division of Nephrology, Department of Pediatrics, University of tables based on normal-weight children, (3) a simplified Screening table for Washington and Seattle Children's Hospital, Seattle, Washington.

3 BDepartments of Pediatrics, Internal Medicine, Population and identifying BPs needing further evaluation, (4) a simplified BP classification Quantitative Health Sciences, Center for Clinical Informatics Research in adolescents 13 years of age that aligns with the forthcoming American and Education, Case Western Reserve University and MetroHealth System, Cleveland, Ohio; cDivision of Pediatric Cardiology, School of Heart Association and American College of Cardiology adult BP guidelines , Medicine, University of Maryland, Baltimore, Maryland; dChildren's (5) a more limited recommendation to perform Screening BP measurements Mercy Hospital, University of Missouri-Kansas City and Children's Mercy Integrated Care Solutions, Kansas City, Missouri; eDepartment only at preventive care visits, (6) streamlined recommendations on the of Pediatrics, School of Medicine, Indiana University, Bloomington, Indiana; fDepartment of Pediatrics, School of Medicine, University initial evaluation and Management of abnormal BPs, (7) an expanded role of Colorado-Denver and Pediatrician in Chief, Children's Hospital for ambulatory BP monitoring in the diagnosis and Management of pediatric Colorado, Aurora, Colorado.

4 GDirector, Preventive Cardiology Clinic, Boston Children's Hospital, Department of Pediatrics, Harvard Medical hypertension, and (8) revised recommendations on when to perform School, Boston, Massachusetts; hDivision of Nephrology, Department of Pediatrics, University of British Columbia and British Columbia echocardiography in the evaluation of newly diagnosed hypertensive Children's Hospital, Vancouver, British Columbia, Canada; Departments pediatric patients (generally only before medication initiation), along with a of iMedicine and Pediatrics, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania; jConsultant, American revised definition of left ventricular hypertrophy.

5 These guidelines include Academy of Pediatrics, Washington, District of Columbia; kCardiology 30 Key Action Statements and 27 additional recommendations derived Division Head, Nemours Cardiac Center, Alfred I. duPont Hospital for Children, Wilmington, Delaware; lNational Pediatric blood pressure from a comprehensive review of almost 15 000 published articles between Awareness Foundation, Prairieville, Louisiana; Departments of mPediatrics and Biomedical Informatics and Medical Education, January 2004 and July 2016. Each Key Action Statement includes level of University of Washington, University of Washington Medicine and evidence, benefit-harm relationship, and strength of recommendation.

6 This Information Technology Services, and Seattle Children's Hospital, Clinical Practice Guideline , endorsed by the American Heart Association, is intended to foster a patient- and family-centered approach to care, reduce To cite: Flynn JT, Kaelber DC, Baker-Smith CM, et al. Clinical unnecessary and costly medical interventions, improve patient diagnoses Practice Guideline for Screening and Management of High and outcomes, support implementation, and provide direction for future blood pressure in Children and Adolescents. Pediatrics. 2017;140(3):e20171904. research. Downloaded from by guest on October 8, 2019. PEDIATRICS Volume 140, number 3, September 2017:e20171904 From the American Academy of Pediatrics 1.

7 Introduction preparation process. Potential thickness (cIMT), flow-mediated conflicts of interest were addressed dilation (FMD), left ventricular 1. Scope of the Clinical Practice and resolved by the AAP. A detailed hypertrophy (LVH), and other Guideline list of subcommittee members markers of vascular dysfunction? Interest in childhood hypertension and affiliations can be found in the To address these key questions, a (HTN) has increased since the 2004 Consortium section at the end of this systematic search and review of publication of the Fourth Report article. A listing of subcommittee literature was performed. The initial on the Diagnosis, Evaluation, and members with conflicts of interest search included articles published Treatment of High blood pressure in will be included in the forthcoming between the publication of the Fourth Children and Adolescents (Fourth technical report.)

8 Report (January 2004) and August Report). 1 Recognizing ongoing The subcommittee epidemiologist 2015. The process used to conduct evidence gaps and the need for an created a detailed content outline, the systematic review was consistent updated, thorough review of the which was reviewed and approved with the recommendations of the relevant literature, the American by the subcommittee. The outline Institute of Medicine for systematic Academy of Pediatrics (AAP) and its contained a list of primary and reviews. 2. Council on Quality Improvement and secondary topics generated to Patient Safety developed this Practice guide a thorough literature search For the topics not researched by Guideline to provide an update on and meet the goal of providing an using the PICOT format, separate topics relevant to the diagnosis, up-to-date systemic review of the searches were conducted.

9 Not all evaluation, and Management of literature pertaining to the diagnosis, topics (eg, economic aspects of pediatric HTN. It is primarily directed Management , and treatment pediatric HTN) were appropriate for at clinicians caring for children and of pediatric HTN as well as the the PICOT format. A third and final adolescents in the outpatient setting. prevalence of pediatric HTN and its search was conducted at the time the This Guideline is endorsed by the associated comorbidities. Key Action Statements (KASs) were American Heart Association. generated to identify any additional Of the topics covered in the outline, relevant articles published between When it was not possible to 80% were researched by using August 2015 and July 2016.

10 (See identify sufficient evidence, a Patient, Intervention/Indicator, Table 1 for a complete list of KASs.). recommendations are based on the Comparison, Outcome, and Time consensus opinion of the expert (PICOT) format to address the A detailed description of the members of the Screening and following key questions: methodology used to conduct the Management of High blood pressure literature search and systematic 1. How should systemic HTN (eg, in Children Clinical Practice Guideline review for this Clinical Practice primary HTN, renovascular HTN, Subcommittee (henceforth, the Guideline will be included in the white coat hypertension [WCH], subcommittee ). The subcommittee forthcoming technical report.)