Blood Pressure

Pediatric Elevated Blood Pressure

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While common, pediatric hypertension (diagnosed when elevated blood pressure (BP) is sustained) often goes unnoticed. Hypertension in children and adolescents is a growing health problem. In persons aged three to 18 years, the prevalence of hypertension is 3.6 percent.1 Evidence suggests that elevated BP in childhood increases the risk for adult HTN and metabolic syndrome.2 Put simply youth with higher BP levels in childhood are also more likely to have persistent HTN as adults.3,4 

Pediatric elevated blood pressure (signs) is misdiagnosed in 74-87% of patients, often due to the need to apply age-sex-height specific blood pressure parameters to identify when a blood pressure is elevated.5,6 Given its low rate of recognition, more awareness of pediatric hypertension is needed among clinicians to improve early diagnosis and recognition.  

Measuring Your Progress

To screen, recognize, and diagnose patients with pediatric elevated blood pressure: 

  • Consider the following inclusion and exclusion criteria for data collection: 

    Inclusion Criteria – All patients that are both 3 years and older (based on the first day of the data collection month) and who also have elevated blood pressure noted at triage during an encounter with the physician during the month in question.  

    Exclusions – Patient must be 3 years old or older by the first day of the month, and the patient chart must note if the blood pressure was taken in the practice triage.  

  • Identify 10 patients each month with an elevated systolic or diastolic blood pressure.   

  • Consider the Project RedDE! Conceptual Model for Pediatric Elevated Blood Pressure:

    • SCREEN: Was patient screened for elevated BP? 

    • RECOGNIZE: Did the provider document the BP percentiles? / Did Provider document that BP was elevated? 

    • DIAGNOSE: Did the provider take appropriate action? 

      • Recheck and document

      • Plan to recheck

      • Refer to specialist for BP

      • Order labs/studies

For more details on the above measures, please see the measures grid.

Tools to support Reducing Diagnostic Errors in Pediatric Elevated Blood Pressure 

Top Tools:

At the end of the project, we surveyed participants on the tools they found to be most useful. The following is a list ranked in order of what was most helpful throughout the course of the collaborative.

  1. Blood Pressure Norms  This table describes screening blood pressure values, which should prompt further evaluation by the clinician, as outlined in the AAP Clinical Practice Guideline (CPG) for Screening and Management of High Blood Pressure in Children and Adolescents. 

  2. AAP Clinical Practice Guideline for Screening and Management of High Blood Pressure in Children and Adolescents  The purpose of this report is to update clinicians on the latest recommendations concerning diagnosis, evaluation, and treatment of hypertension in children. 

  3. Importance of Patient Preparation - Grid and Guidance – A guide on proper positioning for assessment of blood pressure. Also see the video below. 

            4. Bladder Cuff Size Guidance – This table provides a list of recommended dimensions for blood pressure cuff bladders.

            5.  ProjectRedDE! Elevated Blood Pressure Mini RCAs – A tool to identify root cause sources, corrective actions, and long-term solutions of an elevated blood pressure problem.

Elevated Blood Pressure Video Testimonials

Watch the below videos of some of the practices that participated in project RedDE! discussing challenges with screening for and diagnosing elevated blood pressure (EBP) and how they addressed and overcame those challenges.

    1. Hansen ML, Gunn PW, Kaelber DC. Underdiagnosis of hypertension in children and adolescents. JAMA. 2007;298(8):874–879.

    2. Chen X, Wang Y.  Tracking of blood pressure from childhood to adulthood: a systematic review and meta-regression analysis. Circulation. 2008;117(25):3171–3180.

    3. Sun SS, Grave GD, Siervogel RM, Pickoff AA, Arslanian SS, Daniels SR.  Systolic blood pressure in childhood predicts hypertension and metabolic syndrome later in life. Pediatrics. 2007;119(2):237.

    4. Juhola J, Magnussen CG, Viikari JS, et al. Tracking of serum lipid levels, blood pressure, and body mass index from childhood to adulthood: The Cardiovascular Risk in Young Finns Study. Journal of Pediatrics. 2011;159(4):584–590.

    5. Brady TM, Neu AM, Siberry G, Solomon B. Increased Provider Recognition of Elevated Blood Pressure in Children.  American Society of Nephrology; 2012; San Diego, CA.

    6. Hansen ML, Gunn PW, Kaelber DC. Underdiagnosis of hypertension in children and adolescents. JAMA 2007; 298:874-9.

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